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AMERICAN  ADDRESSES 


BY 

SIR  BERKELEY  MOYNIHAN,  M.S.,  F.R.C.S. 


'  s:t^ ' 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1917 


Copyright,  1917,  by  W.  B.  Saunders  Company 


PRINTED    IN    AMERICA 


TO 

G.  W.  CRILE 


£ 


<2L 


PREFACE 

The  papers  included  in  this  volume  were  read  in 
Chicago  and  elsewhere  during  October  and  Novem- 
ber, 1917.  I  hope  they  may  help  my  American  col- 
leagues to  some  appreciation  of  the  causes  and 
conditions  of  the  war,  and  afford  some  help  to  them 
in  their  treatment  of  the  many  new  phases  of  surgical 
diseases  with  which  they  will  be  called  upon  to  deal. 

The  papers  represent  not  only  my  own  views  and 
experience,  but  those  of  others  also.  In  forming 
my  opinions  upon  the  several  matters  discussed  I 
have  received  very  great  help  from  the  many  con- 
sultations and  discussions  I  have  had  with  many  of 
my  friends  in  the  different  war  zones  of  France  and 
England.  I  may  most  appropriately  and  appreci- 
atively quote — 

"I  have  gathered  a  posie  of  other  men's  flowers 
And  nothing  but  the  thread  that  binds  them  is  mine  own." 

Berkeley  Moynihan 

November,  1917 


CONTENTS 


PAGE 


The  Causes  of  the  War 11 

Gunshot  Wounds  and  Their  Treatment 33 

Wounds  of  the  Knee-joint 73 

On  Injuries  to  the  Peripheral  Nerves  and  Their 

Treatment 89 

Gunshot  Wounds  of  the  Lungs  and  Pleura 117 


AMERICAN  ADDRESSES 


THE  CAUSES  OF  THE  WAR 

CONVOCATION  ADDRESS  TO  THE  AMERICAN  COLLEGE 
OF  SURGEONS 

"How  happy  is  he  born  or  taught. 
That  serveth  not  another's  will; 
Whose  armour  is  his  honest  thought. 
And  simple  truth  his  utmost  skill!" 

What  is  this  war  about?  How  has  it  come  about 
that  America  and  England  are  standing  side  by  side 
in  SO  bitter  and  stern  a  conflict  against  Germany  and 
Austria?  What  are  the  strange  circumstances  which 
at  last  have  ranged  against  the  Central  Powers  of 
Europe  almost  all  the  free  peoples  of  the  world? 

No  doubt  many  answers,  each  conflicting  with  the 
rest,  and  yet  each  containing  some  small  grain  of 
truth,  may  be  given  to  these  questions.  We  may  say, 
for  example,  that  we  fight  against  the  continued  ag- 
gression of  Prussia  and  those  other  German  and 
Austrian  powers  whom  Prussia  has  inspired  and  in- 
stigated. No  one  who  reads  history  with  an  unbiased 
mind  can  doubt  that  Prussia  has  increased,  often 
if  not  always,  at  the  expense  of  other  states  by  acts 

11 


12  AMERICAN  ADDRESSES 

of  sudden  and  unprovoked  aggression.  Certainly, 
from  the  hour  when,  in  the  midst  of  peace,  Prussia 
laid  rude  and  violent  hands  upon  Silesia,  her  own 
aggrandisement,  her  territorial  increase,  and  her 
growth  in  power  and  possessions  outside  her  own 
borders,  have  been  due  to  the  wars  she  has  waged. 
War  is  the  National  industry  of  Prussia;  it  is  her 
means  of  acquiring  wealth ;  it  is  by  her  military  suc- 
cesses that  she  has  enlarged  her  borders,  added  to  her 
own  infertile  lands,  solidified  her  gains,  and  been 
able  to  prepare  for  a  still  further  attack  upon  her 
next  chosen  victim.  States  may  advance  in  power, 
and  in  all  that  power  implies,  in  wealth  and  pros- 
perity, and  in  the  happiness  of  its  citizens,  by  ac- 
quisition from  without,  or  by  growth  from  within, 
by  discovery  and  development  of  its  own  resources, 
and  by  directing  all  the  energies  and  talents  of  its 
people  to  its  own  internal  advancement.  No  state  in 
history  can  compare  with  Prussia  in  its  exploitation 
of  the  doctrine  of  plunder;  the  doctrine  of  taking 
because  it  has  the  power,  and  of  keeping  because  it 
has  the  strength  to  do  so.  Quite  consciously  and  quite 
unabashed  she  has  possessed  and  gloried  in  the  pos- 
session of  this  power,  has  fostered  it,  and  with  de- 
liberate and  frank  intention  has  exerted  it  at  her 
own  time  and  for  her  own  ends.  She  sought  dominion. 


THE  CAUSES  OF  THE  WAR  13 

she  had  her  own  confident  and  unwavering  conviction 
of  her  power  to  seize  it,  and  of  all  the  means  by  which 
it  was  firmly  to  be  held.  From  her  point  of  view  she 
had  every  reason  to  think  her  methods  were  right. 
Not  for  one  instant,  of  course,  did  she  call  in  question 
the  principles,  or  doubt  the  ideals,  which  underlie  her 
action.  The  Greatness  of  Prussia,  the  Dominion  of 
Prussia,  which  grew  at  last  into  the  lust  for  World 
Dominion  by  Germany,  were  embedded  deep  in  the 
very  fabric  of  the  Prussian  mind.  Perhaps  not  so 
much  embedded  as  incorporated,  distributed,  that 
is,  equally  land  generously  through  every  part  of  her 
national  consciousness.  The  successes  of  1864,  1866, 
1870  are,  even  at  this  long  distance  of  time,  stupen- 
dous not  so  much  in  their  material  results,  remarkable 
as  these  were,  but  in  their  disclosure  of  a  mighty  and 
well-ordered  power  that  seemed  to  move  irresistibly 
along  a  predestined  path,  to  a  goal  which  had  been 
long  foreseen  and  calmly  and  securely  chosen.  Never, 
it  is  safe  to  say,  in  warfare  before  had  plans  been  so 
carefully  laid,  never  had  they  matured  in  more  per- 
fect accord  with  such  design.  In  this  war  also  we 
learned  without  surprise  that  the  official  communique, 
published  in  Berlin  in  the  first  weeks  of  the  war,  told 
with  laconic  precision  that  '*  everything  proceeded 
according  to  plan."    If  anything  on  earth  was  in- 


14  AMERICAN  ADDRESSES 

fallible,  surely,  said  the  German  nation,  our  army 
and  its  leaders  are  infallible.  The  motive  of  the  war, 
if  this  answer  were  true,  would  be  Germany's  am- 
bition. 

Or,  we  may  answer  my  question  differently.  We 
may  say  that  Germany  had  grounds  for  her  belief 
that  she  was  a  nation  encircled  by  hostile  powers, 
jealous  of  her  splendid  growth,  of  her  swift  acquisi- 
tion of  wealth,  of  that  armed  strength  afloat  and 
ashore,  to  which  she  added  daily.  And  we  may  listen 
to  her  passionate  utterance  that  her  access  to  blue 
water  was  barred,  her  commerce  crippled,  that  she 
was  denied  that  "place  in  the  sun"  to  which  her 
might  entitled  her.  We  can  understand  Germany, 
though  we  cannot  for  one  instant  agree  with  her 
when  she  says  that  for  her  this  was  a  war  of  defence, 
that  she  is  fighting  for  a  way  out  of  the  strong  iron 
bastion  that  had  been  built  up  around  her  frontiers. 
Prussia  in  her  early  days  never  had  a  frontier,  and 
her  first  conscious  act  as  a  nation  was  to  forge  out 
of  her  army  the  frontier  which  nature  had  denied  to 
her.  The  motive  of  the  war,  if  this  answer  were  true, 
would  be  Germany's  fear:  fear,  the  black  godmother 
of  cruelty. 

These  are  the  conflicting  answers  that  may  be 
given  by  one  side  or  the  other.   But  anyone  who  has 


THE  CAUSES  OF  THE  WAR  15 

given  thought  to  the  matter  (and  who  has  not?)  must 
agree  that  whatever  else  this  ghastly  conflict  now  is, 
it  is  in  simple  truth,  not  a  clash  of  merely  material 
interests.  This  is  a  moral  war.  It  is  a  holy  war  if 
ever  there  was  one.  It  is  deep  down  a  war  between 
conflicting  and  discordant  and  unconformable  moral 
systems.  It  is  a  war,  therefore,  in  which  a  real  peace 
cannot  come  by  compromise;  for  you  cannot  come  to 
any  terms  but  one,  with  that  which  you  feel  to  be  a 
principle  of  evil,  with  that  which  you  feel  in  your  in- 
nermost soul  to  be  the  deadliest  enemy  to  mankind, 
and  the  most  menacing  blight  with  which  civiliza- 
tion has  ever  been  threatened. 

What  then  are  the  issues  at  stake  .^^  How  is  the 
question  I  put  to  be  answered.^ 

Let  us  examine  the  principles  which  appear  to 
underlie  the  action  of  the  protagonists  in  this  very 
whirlwind  of  war.  The  principle  ground  into  the 
very  fibre  of  the  German  peoples,  accepted  by  them, 
gloried  in  by  them,  worshipped  by  them,  inspiring 
them,  is  the  principle  of  Tyranny.  What  exactly  is 
meant  by  that?  It  implies  a  complete  surrender  of 
individual  rights  and  liberties,  and  an  unquestioning 
submission  of  them  to  a  power  exercised  exclusively 
from  without.  This  power  may  be  called  the  State, 
or  the  Dynasty,  or  it  may  be  a  ruling  caste.     It  is 


16  AMERICAN  ADDRESSES 

something  outside  and  above  the  individual,  uncon- 
trolled by  him,  owning  no  allegiance  to  him,  but  di- 
recting him  and  ordering  all  his  actions  in  a  manner 
and  with  a  purpose  which,  he  is  told,  are  for  the  benefit 
not  onl}^  of  the  paramount  authority,  but  incidentally 
or  consecutively  of  himself.  Tyranny,  that  is  to  say, 
is  the  power  exercised  by  an  irresponsible  autocracy; 
it  is  the  supremacy  of  the  State  carried  to  its  ultimate 
expression;  and  it  is  by  implication  an  attribute  of 
every  individual  in  the  State.  This  is  no  ignoble 
creed,  and  Prussia,  let  us  tell  it  to  her  credit,  has  made 
a  robust  philosophy  of  it,  and  has  gained  the  staunch 
and  willing  adhesion  to  it  of  almost  every  man  in  her 
nation.  Vigour  and  efiiciency  are  the  practice  of  this 
creed;  that  "might  is  right"  is  the  law  by  which  it 
lives;  courage  is  its  inspiration;  in  success  is  found 
its  ample  apology.  Treitschke  tells  us  in  terms  that 
cannot  be  misunderstood  that  the  "State  is  Power," 
and  that  nothing  can  conflict  with  the  State's  duty 
to  uphold  and  extend  itself  by  the  exercise  of  might. 
This  is  in  truth  the  "Religion  of  Valour." 

Over  against  this  what  have  we  to  set  up,  on  our 
side,  as  our  standard?  What  is  the  principle  by 
which  we  are  sustained  .^^  whence  do  we  derive  our 
soul's  refreshment.'^  It  is  hard  to  find  the  precise 
word,  but  none  fits  so  well  as  Liberty.  And  by  liberty 


THE  CAUSES  OF  THE  WAR  17 

we  mean  here  the  inahenable  and  indestructible  right 
of  every  human  being  to  express  himself,  to  be  him- 
self, to  develop  from  within.  The  relationship  of  a 
man  endowed  with,  and  encompassed  by,  such  lib- 
erty, to  the  State  is  simple  enough.  The  laws  which 
govern  and  control  him  are  laws  which  he  himself 
has  helped  to  make,  and  to  which  he,  with  others  like 
him,  willingly  conforms,  not  so  much  because  the  laws 
are  good,  but  because  they  are  laws  which  he,  and 
those  who  have  gone  before  him,  have  in  freedom, 
imposed  upon  themselves.  This  is  democracy.  To 
us  as  surgeons  practising  a  scientific  profession  the 
conflict  between  these  irreconcilable  principles  is  of 
deep  significance.  For  let  us  consider  their  applica- 
tion to  education. 

Tyranny,  in  the  sense  in  which  I  have  used  it, 
means  that  every  unit  in  the  nation  must  receive  an 
imprint,  a  stamp  from  the  State,  indicating  his  train- 
ing and  value.  The  doctrine  of  tyranny  implies  that 
for  the  service  of  the  State  every  individual  must 
receive  such  training  as  will  fit  him  to  be,  and  ensure 
his  becoming,  a  willing  and  obsequious  servant  of 
the  State.  This  necessarily  implies  the  possession, 
or  the  capture  by  the  State,  of  all  the  machinery  of 
education.  Is  this,  in  fact,  what  has  happened  in 
Prussia  and  in  Germany.?    There  can  be  no  doubt 

2 


18  AMERICAN  ADDRESSES 

whatever  about  the  answer.  The  German  educa- 
tional machine  is  an  absolutist  machine,  a  possession 
of  the  central  authority,  exactly  as  is  the  navy  or  the 
army.  Bismarck  said,  on  August  11,  1893:  "The 
school  is  an  important  part  of  Germany's  national 
institutions.  The  German  school,  like  the  German 
corps  of  officers,  is  a  specifically  German  institution 
which  no  other  nation  can  easily  copy.  In  the  course 
of  the  last  few  decades  the  seed  sown  by  the  schools 
among  the  youth  has  borne  fruit  and  has  given  us  a 
national  political  consciousness  which  formerly  we 
lacked.  The  most  potent  influence  which  the  body 
of  the  teachers  brings  to  bear  upon  German  national 
education  consists  in  this,  that  when  the  German 
teacher  receives  the  child  its  mind  is  like  a  white 
sheet  of  paper.  What  the  teacher  writes  on  it  is 
written  with  indelible  ink.  It  remains  for  life.  The 
youthful  soul  is  soft  and  receptive,  and  we  all  know 
that  we  never  forget  what  we  have  been  taught  be- 
tween the  ages  of  seven  and  fifteen  years.  The 
lessons  then  impressed  upon  us  guide  us  forever. 
In  this  receptivity  of  youth,  in  the  fact  that  the  minds 
of  people  may  at  an  early  age  be  molded  for  all  time, 
lies  the  power  which  the  German  teachers  have  over 
Germany's  future.  As  I  have  said  on  a  former  occa- 
sion, he  who  controls  the  schools  controls  the  future." 


THE  CAUSES  OF  THE  WAR  19 

Education  in  Germany  may  be  obtained  in  pub- 
lic or  in  private  institutions.  The  last  figures  avail- 
able showing  the  number  of  students  attending  Ger- 
man schools  are  for  the  year  1911.  ,In  that  year  there 
were  11,050,620  pupils  in  public  schools,  as  against 
126,278  in  private  schools — a  proportion  of  88  to  1. 
In  Prussia  alone  the  numbers  were  6,674,989  in  pub- 
lic schools  to  8996  in  private  schools — a  proportion 
of  nearly  750  to  1.  The  importance  of  this  gigantic 
difference  is  realised  when  it  is  understood  that  the 
teachers  in  the  public  schools  "have  the  rights  and 
duties  of  State  officials";  that  is,  they  may  prune 
themselves  with  all  the  petty  arrogance  which  is 
inseparable  from  a  Teutonic  official,  but  they  must 
submit  to  that  iron  discipline  which  regulates  their 
conduct,  and  must  curry  favour  with  that  stern  and 
unbending  authority  upon  which  their  academic 
career  entirely  depends.  And  this  firm  and  unrelenting 
grip  fastens  also  upon  the  universities  and  upon  every 
professor.  None  can  hope  for  promotion,  or  for  those 
titles  and  distinctions  which  are  so  precious,  unless  he 
is  in  all  essential  things  in  agreeable  conformity  with 
those  who  exercise  control.  "No  scientist,  however 
eminent,  can  hope  to  obtain  a  professorship  in  Prussia 
if  he  is  persona  ingrata  with  the  government,  and 
a  professor  who  opposes  the  government,  unless  he 


20  AMERICAN  ADDRESSES 

acts,  with  the  greatest  moderation  and  circumspec- 
tion, is  likely  to  lose  his  position  and  income."  The 
German  government  exercises  practically  unlimited 
influence  over  the  universities  rather  by  indirect 
than  by  direct  means.  The  university  professors  can 
be  controlled  or  cajoled  by  the  Minister  of  Educa- 
tion, who  exercises  vast  powers  and  distributes  a 
valuable  patronage.  All  of  us  know  how  influences 
of  this  kind  may  be  wielded,  and  how  swift  and  heavy 
may  be  the  visitation  for  a  grave  offence. 

The  State,  then,  in  Germany  not  only  owns  the 
educational  establishment,  but  elects  and  trains  the 
teachers  in  the  several  grades  of  schools,  confers  upon 
them  the  rights,  and  exacts  from  them  the  duties,  of 
State  officials,  and  finally  exerts  a  firm  and  purpose- 
ful direction  upon  the  instruction  given  to  all  pupils. 
For  its  own  objects  the  State  uses  the  didactic  weapon 
with  a  strong  hand  and  a  far-seeing  and  ruthless  pur- 
pose, and  she  makes  no  secret  of  her  intentions.  The 
Kaiser  himself,  in  an  educational  address,  has  said, 
speaking  of  the  use  of  the  school  as  a  political  weapon : 
"If  the  school  had  done  what  must  be  demanded  of  it, 
it  should  at  once  and  on  its  own  motion  have  under- 
taken the  fight  against  social  democracy.  The  teach- 
ing boards  ought  to  have  combined  and  ought  with 
energy  to  have  instructed  the  growing  generation  in 


THE  CAUSES  OF  THE  WAR  21 

such  a  manner  as  to  furnish  me  with  material  with 
which  I  can  work  within  the  State.  Then  it  would 
have  been  easy  to  overmaster  quickly  the  Socialist 
movement";  and  again:  "Men  who  support  Radical 
Utopias  can  as  little  be  employed  in  education  as  they 
can  be  employed  in  the  government  offices";  and 
that  this  view  of  the  duty  of  the  State  to  use  this  in- 
strument still  continues  we  have  the  authority  of 
Friedel,  who  states  that  today  "both  the  Prussian 
government  and  the  Imperial  Government  of  Ger- 
many were  stealthily  taking  every  step  towards  a  cen- 
tralization of  control  of  German  education  in  order 
that  under  the  political  influences  of  the  Imperial 
Government  every  school,  every  university,  and  every 
educational  outpost  of  Germany  after  the  war  might 
respond  at  once  to  instructions  from  the  centre, 
and  use  their  intellectual  propaganda  for  Germanic 
ends."  German  education,  both  before  the  war  and 
since  the  war  began,  has  indeed  been  a  master  weapon 
in  the  hands  of  the  military  party,  and  there  is,  as 
we  learn  without  surprise,  every  intention  that  the 
strength  of  this  implement  shall  be  used  as  ruthlessly 
as  ever  in  the  service  of  the  State.  There  is  evidence, 
M.  E.  Sadler  tells  us, — and  there  is  no  better  in- 
formed authority, — that  in  Germany  there  has  re- 
cently been  a  huge  wave  of  national  feeling  expressing 


22  AMERICAN  ADDRESSES 

itself  in  demands  for  emphasis  upon  those  subjects 
which  would  fill  the  minds  of  boys  and  girls  with  a 
sense  of  glory  in  the  German  past,  of  confidence  in  the 
German  future,  and  with  some  contempt  for  Ger- 
many's enemies.  These  efforts  are  not  restricted  to 
domestic  matters.  We  know  that  measures  are  being 
taken  to  extend  the  sphere  of  German  influence, 
through  the  medium  of  education,  in  Turkey,  and  the 
Balkans,  and  in  Latin  South  America,  not  only  by 
the  government,  but  by  the  business  men  and  by  in- 
structed public  opinion. 

This  brief  exposition  of  Germany's  educational  aims 
does  not  attempt,  or  desire,  to  deny  the  many  and  great 
achievements  which  can  most  justly  be  placed  to  their 
credit.  The  average  German  student  was  well  taught, 
even  if  the  things  he  learned  were  not  always  a  sober 
reflection  of  the  truth;  even  if  truth  were  held  of  less 
account  than  expediency.  A  multitude  of  talents  may 
not  inaccurately  describe  the  German  nation,  con- 
sidered from  the  educational  standpoint.  A  nation  so 
organized  and  so  instructed  may,  indeed,  as  all  the 
world  has  learned,  be  either  a  mightj^  influence  for 
good,  or  a  strong  and  sinister  implement  of  mischief. 
"Opinion  in  Germany,"  says  a  well-informed  and 
credible  writer,  "from  the  cradle  to  the  grave,  has 
been  controlled  and  directed  by  the  military,  Macht- 


THE  CAUSES  OF  THE  WAR  23 

politik,  and  the  policy  of  ruthlessness  in  warfare  is, 
therefore,  unanimously  advocated  by  soldiers  and  citi- 
zens, scientists  and  clergymen,  merchants  and  Roman 
Catholic  priests." 

This  is,  in  my  belief,  a  fair  statement  of  the  effect 
of  the  principle  of  tyranny  applied  to  educational 
methods  and  propaganda. 

The  principle  of  liberty  acts  far  otherwise.  This 
implies  the  desire  and  intention  of  those  responsible 
for  the  teaching  of  the  nation  that  the  individual 
shall  develop,  morally  or  intellectually,  from  within; 
that  by  education  he  shall  be  given  the  power  and 
enjoy  the  opportunity  of  self-development  and  learn 
the  manner  of  self-expression.  Where  Germany  seeks 
to  nurture  in  each  child  the  gifts,  and  the  measure 
of  those  gifts  in  so  far  as  they  may  be  of  direct  ser- 
vice to  the  State,  the  system  of  liberty  desires  the 
fullest  development  of  all  the  natural  powers  in  order 
that  in  their  own  measure  and  stature  they  shall  be 
available  for  the  common  good.  And  so  by  the  Ger- 
man method  instruction  of  the  hard-and-fast  kind 
extends  to  all  branches  of  learning.  I  remember  well, 
only  a  month  before  the  war,  discussing  with  a  dis- 
tinguished German  colleague  some  aspects  of  English 
literature  and  some  gifts  and  qualities  of  the  men  who 
had  bequeathed  to  us  the  splendid  heritage  which  is 


24  AMERICAN  ADDRESSES 

the  chief  glory  shared  by  all  who  speak  our  common 
tongue.  I  was  struck  not  only  by  the  variety,  but 
also  by  the  rapidity  of  the  judgments  expressed. 
When,  for  example,  Galsworthy  was  mentioned, 
there  came  a  clear  and  crisp  opinion,  precise,  uncom- 
promising, devoid  of  qualification  or  of  illustration. 
I  wondered  at  the  swift  precision  until  a  few  minutes 
later  we  came  to  speak  of  Oscar  Wilde.  Now  Wilde, 
with  all  his  subtly  interwoven  virtues  and  defects, 
cannot  be  expressed  in  an  epigram  or  summarised 
and  dismissed  in  a  phrase.  Yet  in  this  case  again  I 
had  to  listen  to  a  curt  and  neat  and  exact  survey  of 
Wilde's  position  among  modern  authors.  I  was  lost 
in  stupefaction,  but  had  the  curiosity  to  ask  if  my 
adversary  in  this  friendly  debate  had  read  much  of 
Wilde's  work.  And  quite  frankly  the  confession  was 
made  that  not  one  volume  of  this  author  had  been 
read.  The  opinions  to  which  I  had  listened  with  real 
interest  were,  so  I  learned,  those  held  in  Germany, 
taught  in  her  schools,  and  humbly  accepted  as  apt 
and  accurate.  Even  in  a  matter  so  remote  from  any 
bureaucratic  importance  there  was,  so  to  speak,  the 
ofiicial  and  authoritative  opinion.  Here,  as  often 
before,  the  German  people  would  seem  to  hold  a 
"herd"  opinion  upon  many  problems,  and  to  express 
them  in  identical  phrases.     This  little  illuminating 


THE  CAUSES  OF  THE  WAR  25 

experience  seemed  to  me  to  have  its  own,  and  a  very- 
real,  significance,  and  to  contrast  quite  sharply  with 
what  would  have  happened  if  I  had  been  discussing 
this  matter  with  a  fellow-countryman.  He  indeed 
might  never  have  read  Wilde,  though  probably  he 
would  have  seen  one  of  his  most  charming  plays; 
if  he  had  read  Wilde  he  might  not  have  thought  it 
worth  while  to  form  an  opinion  about  him  as  a  writer 
of  English  prose;  but  it  is  quite  certain  that  if  he 
expressed  an  opinion  it  would  be  his  own  opinion, 
whether  right  or  wrong.  "A  small  thing  but  mine 
own"  he  might  have  said  apologetically. 

Is  then  the  German  system  really  educational.'^  It 
is,  I  believe,  a  mistake  to  assume  that  the  present 
highly  organised,  well-planned,  systematic  instruc- 
tion in  the  German  schools  really  educates  the  Ger- 
man people.  It  puts  upon  their  minds  too  many 
ready-made  opinions,  disposes  them  too  easily  to 
accept  the  judgments  of  experts  on  subjects  with 
which  they  are  not  familiar;  it  departmentalizes  Ger- 
man opinion  and  prevents  the  ordinary  German  citi- 
zen from  forming  his  own  judgment  on  the  profound- 
est  political  and  moral  issues  while  giving  him  an 
overflowing  consciousness  of  excellence. 

The  system  of  liberty,  on  the  one  hand,  desires 
rather  to  develop  and  strengthen  the  character  of  the 


26  AMERICAN  ADDRESSES 

future,  citizen;  the  system  of  tyranny  seeks  to  train 
and  stamp  the  intellect  with  a  certain  quality.  It  is 
free  natural  growth,  on  the  one  hand;  it  is  repressive 
and  specific  culture,  on  the  other. 

The  one  comment,  or  perhaps  I  may  without  in- 
justice say  the  one  unfavourable  criticism,  that  I  have 
heard  passed,  in  Germany  and  elsewhere,  about  our 
English  system  of  education  is  that  we  place  too  much 
stress  upon,  and  indeed  waste  most  precious  and  irre- 
claimable time  upon,  the  playing  of  games.  In  every 
English  school  much  is  made  of  this  playing  of  all 
team  games.  In  my  day,  and  I  hope  it  is  so  still, 
more  was  thought  by  his  school  fellows  of  the  athletic 
achievements  of  a  boy  than  of  his  intellectual  prowess 
in  the  schools.  In  the  development  of  a  boy's  char- 
acter, along  the  lines  which  in  my  country  most 
fathers  wish  their  boys  to  go,  the  playing  of  games  is 
the  most  powerful  and  salutary  influence.  The  games 
are  those  in  which  a  boy  who  is  by  nature  an  egoist 
learns  that  it  is  the  right  thing  to  play  for  his  side. 
-He  learns  that  it  is  not  individual  success  that  counts, 
but  victory  for  his  team.  Self  is  merged  in  the  side 
for  which  he  plays.  And  by  degrees  he  learns  an- 
other lesson  more  valuable  still.  It  is  that,  though 
quite  rightly  he  may  strive  for  victory,  it  is  not  only 
victory  that  counts.    He  learns  to  play  not  for  the 


THE  CAUSES  OF  THE  WAR  27 

goal,  but  for  the  game.    He  finds  that  it  is  a  nobler 
thing  to  play  cleanly  than  it  is  merely  to  win.    And 
he  finds,  too,  not  only  in  his  youth,  but  through  all 
his  life,  that  the  finest  epitaph  that  any  man  can  earn 
is  this,  "He  played  the  game" — not,  I  beg  you  to 
notice,  "He  won  the  game,"  or  that  he  achieved  this 
or  that  most  coveted  honour  or  distinction,  but  just 
simply  that  he  "played"  the  game.    Even  in  this  war  I 
think  we  have  an  illustration  of  this  very  point. 
Many  new  devices  have  come  to  the  aid  of  all  the 
armies,  and  such  science  as  each  nation  possesses  has 
been  called  in  to  aid  the  combatants.    Is  it  not  inter- 
esting that  all  the  dirty  dodges,  the  gas  attacks,  the 
liquid  fire,  the  bombardment  of  open  towns,   the 
metamorphosis  of  neutral  embassies  into  bacterio- 
logical laboratories,  the  unrestricted  use  of  subma- 
rines, have  all  come  from  one  side.^^    And  is  it  not  in- 
teresting that  so  many  of  the  real  and  honest  devices, 
barrage  fire,  tanks,  hand  grenades,  have  come  from 
the  other?    It  is  satisfactory  to  know,  however,  that 
when  the  Allies  are  compelled  to  retaliate,  as  they 
did  very  tardily  and  regretfully,  for  example,  in  the 
matter  of  gas  attacks,  the  morbid  ingenuity  of  the 
German  recoils  upon  himself  very  heavily.     In  these 
matters,  so  far  as  we  have  had  to  make  a  rejoinder, 
the  Gertaian  is  now  surpassed  both  by  the  French  and 


28  __  AMERICAN  ADDRESSES 

ourselves.  It  would,  as  a  piece  of  practical  policy 
have  paid  the  enemy  better  to  have  "played  the 
game."  The  response  may  indeed  be  made  that  this 
notion  of  playing  the  game  for  what  the  game  is 
worth  is  not  enough;  that  victory  and  the  fruits  of 
victory  are  really  the  ends  in  view.  But  we  as  sur- 
geons know  better.  We  are  at  work  in  our  profession 
for  the  sake  of  the  task,  not  for  the  tribute  that  we 
exact  for  our  services.  Our  delight  and  our  recom- 
pense are  in  the  good  work  we  are  able  to  do,  not  in 
any  paltry  or  imperfect  pecuniary  recognition  of  our 
value.  We  practise  that  in  a  profession,  not  a  trade, 
and  life  is  the  most  splendid  and  the  most  arduous 
profession  of  all.  The  development  of  a  man's  charac- 
ter, which  allows  the  fullest  expression  of  a  man's  life, 
is,  therefore,  the  motive  and  the  mark  of  all  methods 
of  liberal  education.  It  is  the  "drawing  out"  of 
something  from  the  man  himself  (for  that  is  what 
education  means) ,  as  contrasted  with  the  something 
driven  in,  by  the  usages  of  the  method  of  tyranny.  It 
is  something  added  to  the  mere  building  up  and  shap- 
ing of  a  man's  mind.  There  is  a  charming  legend 
in  one  of  the  Apocryphal  gospels.  Some  little  children 
were  sitting  by  the  wayside  playing,  and  making  mud 
sparrows,  when  the  Holy  Child  passed  that  way  and 
took  the  sparrows  in  his  hands,  warmed  them  in  his 


THE  CAUSES  OF  THE  WAR  29 

bosom,  breathed  upon  them,  and  released  them  to 
fly  into  the  heavens.  This  should  be  the  impulse  of 
liberty — an  influence  carrying  life  and  freedom  and 
ecstasy  with  it.  And  what  may  we  hope  the  quali- 
ties of  a  whole  nation  to  be  whose  individual  members 
are  brought  up  in  these  ideals  and  by  these  methods.^ 
Let  us  hope  that  they  are  justice  in  administration, 
steadfastness,  a  spirit  of  tolerance,  and  moderation 
in  victory. 

And  in  the  practice  of  our  profession  am  I  in  error 
in  thinking  that  I  have  noticed  among  those  trained 
in  the  ideals  of  liberty  a  gentler  approach  to  the  in- 
dividual patient,  a  more  anxious  consideration  for  his 
welfare,  and  a  more  tender  sympathy  and  compas- 
sion for  his  suffering  than  is  found  among  that  people 
for  whom  technical  skill  counts  more  in  public  esteem 
than  do  qualities  of  character  .^^ 

We  have  then  in  this  war,  as  I  believe,  these  con- 
flicting and  contending  systems,  tyranny  and  lib- 
erty; autocracy  and  democracy;  control  and  re- 
pression from  without,  growth  from  within.  And  I 
am  deeply  persuaded  that  an  issue  for  the  world  of 
science,  almost  as  critical  and  as  grave  as  any  I  have 
mentioned,  is  at  stake  in  our  future.  Tyranny  long 
exercised  must  mean  a  restriction  of  the  intellectual 
outlook,  a  fettering  of  our  thoughts  to  customs  and  to 


30  AMERICAN  ADDRESSES 

ordinances  that  cramp  our  minds,  an  atrophy  from 
long  disuse  of  that  quality  of  mental  effort  which 
makes  for  originality.  Tyranny  implies  the  negation 
of  scientific  progress,  though  the  unrestricted  exercise 
of  its  formulae  may  arrange  in  orderly  precision  all 
the  knowledge  that  others  have  acquired.  Tyranny 
means  at  last  intellectual  sterility  and  death.  How 
impossible  it  is  for  a  nation  held  in  the  grip  of  tyranny 
to  give  its  citizens  intellectual  freedom,  great  though 
its  desire  may  be  to  do  so !  Progress  in  science  must, 
first  and  last,  depend  upon  the  unrestrained  freedom 
of  exercise  of  all  the  faculties  of  the  human  mind. 
Of  these,  imagination  is  perhaps  the  chief.  Imagina- 
tion is  the  mother  of  fact.  Or,  one  may  say,  it  is  the 
scaffold  upon  which  one  stands  to  build  the  structure 
of  truth.  Imagination,  as  Keats  tells  us,  may  be 
compared  to  Adam's  dream — he  awoke  and  found 
it  truth.  It  cannot  surely  live  fn  the  narrow  restric- 
tions and  in  the  dank  and  stiflijig  air  where  the 
noxious  weed  of  tyranny  thrives.  For,  hamper  it  as 
you  will,  thought  in  the  long  run  must  have  its  way, 
which  is  the  way  of  challenge  and  inquiry.  Nor,  I 
think,  can  any  work  of  enduring  value  come  in  the 
absence  of  intellectual  morality,  the  very  existence 
of  which  is  threatened  by  that  surrender  of  truth  to 
expediency  of  which  I  have  spoken.    And  I  believe 


THE  CAUSES  OF  THE  WAR  81 

that  the  history  of  Germany  in  the  last  forty  years 
is  the  most  convincing  argument  that  can  be  brought 
in  favour  of  this  thesis.  In  all  this  period  she  has  dis- 
played amazing  industry,  ungrudging  toil;  she  has 
organised  and  tabulated  and  made  accessible  to  all 
peoples  the  scientific  work  of  every  nation.  She  has, 
indeed,  been  the  intellectual  clearing-house  of  the 
world.  It  would  be  useless  to  belittle  and  impossible 
to  deny  her  intellectual  value  to  the  world.  The  best 
of  her  is  diligence.  But  her  own  original  contribu- 
tions to  science  are,  I  believe  it  to  be  beyond  dispute, 
the  slenderest  of  any  of  the  great  nations  of  the  world. 
Tyranny  is  not  a  force  to  set  ideas  in  motion.  Under 
a  system  of  tyranny  intellectual  salvation  can  come 
only  from  revolt.  How  else  can  we  account  for  the 
eternal  freshness  of  the  Jewish  mind,  and  for  the  splen- 
did achievements  of  that  race  which,  tyrannized  by 
every  power,  has  kept  its  own  religion  and  lived  its 
own  intellectual  life,  not  by  submission,  but  by  re- 
sistance to  those  who  held  its  men  in  bondage? 
Was  not  Pilgrim's  Progress  the  cry  of  an  unfettered 
soul,  and  not  of  the  body  restrained  by  the  bolts  and 
bars  of  Bedford  Gaol.^  And  was  it  not  in  Patmos 
that  St.  John  the  Divine  beheld  the  visions  of  the 
Apocalypse? 

In  this  war,  as  I  see  it,  we  are  fighting  therefore 


32  AMERICAN  ADDRESSES 

for  liberty :  of  the  two  discordant  systems  of  morals, 
one  only  must  triumph  and  survive.  If  we  com- 
promise with  that  which  we  believe  to  be  a  prin- 
ciple of  evil,  a  precursor  of  moral  and  intellectual 
death  and  dissolution,  we  are  false  to  those  who  have 
given  their  most  precious  lives  that  truth  might 
conquer  at  the  last,  but  more  than  this,  we  are  false 
to  those  who  come  after,  we  are  robbing  them  of 
their  birthright,  we  are  shackling  for  generations  to 
come  the  minds  and  the  souls  of  men,  we  are  failing 
in  our  plain  duty  to  humanity. 


GUNSHOT   WOUNDS   AND  THEIR 
TREATMENT 

Surgeons  who  were  responsible  in  the  early  weeks 
of  the  present  war  for  the  treatment  of  the  wounded 
soldiers  coming  home  from  France  are,  I  think, 
never  likely  to  forget  their  experience.  There  were 
wounds  of  many  dimensions  and  of  every  tissue,  all 
characterised  by  the  most  profuse  and  offensive  sup- 
puration. No  one  in  active  work  had  ever  met  with 
cases  like  all  of  these.  Whether  a  surgeon  had  prac- 
tised "aseptic"  or  "antiseptic"  surgery,  he  had  been 
able  to  secure  with  gratifying  constancy  a  blameless 
healing  of  the  wounds  he  had  made;  he  had  rarely 
seen  a  profoundly  septic  wound,  and  the  methods  he 
had  at  his  disposal  for  dealing  with  them  were,  al- 
most always,  easily  capable  of  reducing  and  con- 
trolling the  infection.  Suddenly  he  was  confronted 
with  a  long  succession  of  cases  in  which  a  raging  and 
often  a  rancid  suppuration  was  present,  and  he  found 
that  all  the  old  remedies,  upon  which  he  had  so  com- 
fortably and  so  confidently  relied,  were  hopelessly 
inadequate  and  futile.  A  challenge  was,  so  to  say, 
3  33 


34  -  AMERICAN  ADDRESSES 

thrown  to  the  profession,  and  I  think  we  may  now 
with  due  modesty  claim  that  it  has  been  splendidly 
and  triumphantly  met.  Rebukes  and  taunts  at  our 
incompetence  were  not  seldom  heard  in  those  far- 
off  days.  We  were  asked  if  Lister  had  worked  in  vain; 
and  we  were  told  that  we  had  failed  to  learn  the  lesson 
he  had  spent  his  life  in  teaching. 

It  is  interesting  to  read  again  the  works  of  Lister, 
and  to  see  how  helpless  he  felt  himself  in  dealing 
with  putrefactive  processes  once  firmly  established 
in  a  wound.  Lister  everywhere  distinguishes  be- 
tween the  "prophylactic"  and  the  "therapeutic" 
uses  of  antiseptics.  All  the  marvellous  achievements 
of  modern  surgery  are  due  to  the  adoption,  by  sur- 
geons the  whole  world  over,  of  the  principle  of  the 
prevention  of  infection  in  wounds  about  to  be  made, 
as  distinguished  from  that  of  the  subduing  of  an  in- 
fection already  rampant. 

Lister  writes:  "The  original  idea  of  the  antisep- 
tic system  was  the  exclusion  of  all  microbes  from 
wounds."  Again,  "During  the  operation,  to  avoid 
the  introduction  into  the  wound  of  material  capable 
of  inducing  septic  changes  in  it,  and  secondly  to 
dress  the  wound  in  such  manner  as  to  prevent  the 
subsequent  entrance  of  septic  mischief."  Again, 
"In  wounds  already  septic  attempts  are  made  with 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  35 

more  or  less  success  to  restore  the  aseptic  state." 
Again,  "In  speaking  of  the  antiseptic  system  of 
treatment,  I  refer  to  the  systematic  employment  of 
some  antiseptic  substance  so  as  entirely  to  prevent 
the  occurrence  of  putrefaction  in  the  part  concerned, 
as  distinguished  from  the  mere  use  of  such  an  agent 
as  a  dressing." 

The  distinction  between  the  preventive  and  the 
curative  use  of  antiseptics  is  in  many  respects  that 
existing,  on  the  one  hand,  between  the  power  of  a 
germicide  as  determined  by  experiments  "in  vitro," 
and,  on  the  other  hand,  its  capacity  to  destroy 
organisms  when  it  is  introduced  among  the  living 
and  the  dead  tissues  of  a  wound.  In  the  former  there 
is  a  direct  conflict,  a  clean  fight,  between  the  microbe 
and  the  chemical  agent.  Few  or  none  of  the  many 
intervening  conditions  are  present  which  have  to  be 
considered  when  a  bactericide  is  introduced  into  a 
wound  cavity  wherein  there  are  a  multitude  of  ac- 
tions and  reactions  which  even  now  seem  very  ob- 
scure and  are  so  often  conflicting. 

When,  after  the  lapse  of  many  weeks  from  the 
outbreak  of  war,  there  came  a  full  appreciation  of  the 
several  circumstances  which  had  to  be  reckoned 
with  when  a  soldier  was  wounded,  it  was  recognised 
on  all  hands  that  a  new  and  grave  problem  had 


36  -  AMERICAN  ADDRESSES 

arisen  which  cried  urgently  for  solution.  What, 
then,  were  the  several  new  factors  that  had  to  be 
considered  in  this  war? 

In  the  early  days  a  very  large  number  of  the 
wounds  were  inflicted  by  rifle  fire.  The  German 
bullet  has  a  muzzle  velocity  of  approximately  1000 
yards  per  second.  In  the  first  800  yards  or  there- 
abouts the  flight  of  the  bullet  is  not  steady,  but 
^'wobbling."  There  are  three  movements — a  move- 
ment forward  along  the  line  of  flight;  a  rotatory 
movement,  in  which  the  bullet  spins  round  on  its 
longitudinal  axis  as  a  result  of  the  "rifling"  of  the 
barrel;  and  a  third  movement,  a  "mouvement  de 
bascule,"  of  such  a  character  that  while  the  point 
of  the  bullet  keeps  steady,  the  base  of  the  bullet  is 
moving  round  a  circle,  or  an  ellipse,  of  a  gradually 
diminishing  size.  The  result  of  the  last  form  of 
motion  is  this,  that  when  the  bullet  impinges  upon 
any  substance,  even  the  soft  clothing  or  the  flesh, 
the  infinitely  brief  arrest  of  the  point  which  strikes 
first  allows  the  base,  which  is,  of  course,  much  heavier, 
to  overtake  the  apex,  and  the  bullet  then  lies  side- 
ways or  begins  to  turn  over  and  over  as  it  ploughs  its 
way  through  the  soft  parts.  In  this  early  part  of  the 
trajectory  the  missile  has,  of  course,  a  great  momen- 
tum;  it  is  a  heavy  bullet  traveling  with  great  veloc- 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  37 

ity.  The  consequence  is  that  the  damage  inflicted 
is  not  confined  to  the  track  it  rudely  makes  through 
the  limb;  the  parts  around  the  track  are  damaged 
also,  often  to  a  great  extent,  and  microbes  are  driven 
deeply  into  all  adjacent  tissues.  Every  wound, 
therefore,  caused  by  a  bullet  at  short  range  consists 
not  only  in  a  visible  tearing  and  destruction  along 
the  path  the  bullet  has  followed,  but  in  a  dead  zone 
everywhere  surrounding  that  track — a  zone  in  which 
death  or  destruction  or  disintegration  of  the  parts 
has  occurred  by  reason  of  the  tremendous  concussion 
produced  by  the  bullet  as  it  tore  its  way  clumsily 
through  the  tissues.  Sir  Anthony  Bowlby  has  illus- 
trated this  by  a  series  of  exemplary  instances.  In 
one  of  these  the  kidney  was  wounded  in  its  lower  pole; 
the  upper  pole  appeared  normal  to  the  naked  eye, 
yet  on  microscopic  examination  the  tubules  were 
seen  to  be  disorganised.  Other  examples  of  the  wide- 
spread damage  inflicted  are  quoted  in  his  Bradshaw 
lecture.  And  even  that  is  not  all.  The  momentum 
of  the  bullet  is  such  that  to  everything  it  encounters 
it  imparts  some  of  its  own  velocity.  As  we  all  know, 
shreds  of  the  clothing  or  belt,  or  the  contents  of  the 
pocket,  may  be  carried  deeply  into  a  wound.  So 
also  are  pieces  of  skin  or  muscle.  And  if  the  bullet 
should  chance  to  strike  a  bone,  the  bone  is  not  only 


38  AMERICAN  ADDRESSES 

broken  into  many  fragments, — the  "splinter"  frac- 
ture,— but  to  all  fragments  there  is  conveyed  enough 
of  the  momentum  of  the  bullet  to  convert  them  into 
projectiles  also,  capable  of  tearing  a  way  into  the 
softer  tissues.  Many  of  the  wounds,  therefore, 
were  deep,  irregular  in  shape,  with  large  or  small 
cavities,  of  the  variety  the  French  term  "anfractu- 
ous." Into  these  recesses  blood  escapes,  and,  owing 
to  the  tearing  and  unequal  retraction  of  cut  muscles, 
pools  of  fluid  may  be  shut  off  from  the  main  track 
of  the  wound  and  form  an  ideal  breeding-ground 
for  all  microorganisms,  especially  those  which  are 
anaerobic. 

If  a  rifle  bullet  is  not  checked  in  the  first  600  yards 
of  its  flight,  it  begins  to  steady  down,  and  probably 
when  it  has  traveled  1000  yards  it  is  moving  evenly. 
An  injury  inflicted  then  is  of  a  quite  different  char- 
acter. The  bullet  cleaves  its  way  through  the  soft 
parts,  bores  a  neat  hole  through  a  bone,  and  little 
destruction  is  done.  We  see  many  cases  where  the 
chest  or  abdomen  is  traversed  from  side  to  side,  or 
where  the  neck  has  been  pierced,  and,  miraculously, 
no  real  damage  has  been  done.  Examples  of  this 
form  of  injury  were,  of  course,  common  enough  in 
the  South  African  war.  They  have  been  less  fre- 
quent in  this  war  because  the  range  has  often  been 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  39 

shorter,  and  the  bullet,  in  respect  of  velocity  and 
weight,  is  different. 

During  the  last  two  years  a  very  large  proportion 
of  the  wounds  have  been  inflicted  by  shrapnel  bul- 
lets, hand  grenades,  or  shell  casing.  The  immense 
velocity  of  the  projectiles,  especially  when  a  high  ex- 
plosive shell  bursts,  their  irregular  shape,  their  pitted 
surface  and  sharp  edges  all  combine  to  cause  wounds 
of  very  diverse  forms.  The  track  is  a  distorted  one, 
the  parts  around  it  are  bruised  and  battered  or  dead, 
and  the  infection  carried  into  the  wound  by  a  piece 
of  metal  or  cloth  has  unrestricted  opportunities  of 
spreading  rapidly.  In  many  cases  large  areas  of  the 
limbs  or  trunk  are  blown  away;  the  wound  remaining 
shows  a  shattered  and  irregular  surface;  the  muscles 
are  torn  and  crushed,  or  '* pulped,"  and  lose  their 
structure.  They  dry  rapidly  on  exposure,  and  there- 
fore fall  easy  victims  to  a  bacterial  attack  often  of 
great  ferocity. 

The  condition  of  the  battle-fields  of  Flanders  and 
of  France  accounts  for  the  quality  of  the  infective 
agents.  Many  parts  of  the  lands  over  which  the 
fighting  has  taken  place,  both  before  and  since  trench 
warfare  set  in,  were  cultivated  assiduously  by  the 
rural  inhabitants  before  the  war.  Probably  no  soil 
in  Europe  has  been  more  liberally  manured  in  efforts 


40  ~  AMERICAN  ADDRESSES 

at  intensive  cultivation.  Certainly  no  contact  be- 
tween the  soldier  and  the  soil  has  ever  been  more 
intimate  or  more  protracted.  In  the  winter  the  whole 
fighting  zone  is,  in  Sir  Douglas  Haig's  phrase,  a 
"wilderness  of  mud."  In  the  summer  it  rivals  the 
desert  in  a  sand  storm;  dust  is  everywhere.  It 
steals  into  the  eyes  and  nose  and  throat  and  ears, 
it  grimes  the  face  and  hands,  it  fills  the  hair,  it  pene- 
trates every  vestment.  Every  projectile  passing 
through  the  garments  to  the  body  will  certainly  be 
covered  with  the  mud  or  dust  in  the  clothes,  and  with 
the  many  organisms  that  respite  from  ablutions  has 
allowed  to  penetrate  the  skin.  All  bacteriologists  and 
surgeons  are  now  agreed  that  no  influence  perpetuat- 
ing infection  in  a  wound  is  so  malign  as  that  which 
is  harboured  in  the  torn  fragments  of  clothing.  The 
physical  condition  of  the  soldier  himself,  when  he  is 
wounded,  no  doubt  plays  an  important  part  in  exalt- 
ing the  virulence  of  any  infection  which  may  settle 
upon  him.  Though  in  the  best  of  health  and  physical 
condition  at  the  moment  of  attack,  he  may,  by  the 
time  he  is  wounded,  have  suffered  great  fatigue,  and 
bleak  exposure,  for  hours,  or  even  days,  before  suc- 
cour comes  to  him.  The  organisation  for  the  collec- 
tion and  despatch  to  the  field  ambulances  and  Cas- 
ualty Clearing  Stations  of  wounded  men  is  probably 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  41 

as  perfect  as  any  endeavour  can  make  it.  But  there 
are  times,  especially  in  a  "push,"  when  a  man  may 
lie  out  undiscovered  for  long  periods.  Not  infre- 
quently by  reason  of  such  causes,  and  on  account  of 
pain  and  hunger  and  loss  of  blood,  he  may  be  reduced 
to  a  state  in  which  his  power  of  resistance  to  a  bac- 
terial attack  is  greatly  impoverished. 

BACTERIOLOGY 
The  bacteria  infesting  the  wounds  in  France  have 
been  studied  by  Wright,  Fleming,  and  others.  The 
general  conclusion  drawn  from  their  work  is  that  the 
microorganisms,  as  might  be  expected,  are  those  found 
in  highly  manured  soil;  they  are,  that  is  to  say,  of 
fecal  origin.  Wright  suggests,  with  his  customary 
fecundity  of  invention,  the  new  names  "serophytes" 
for  those  organisms  which  will  grow  in  normal  serum, 
streptococci,  and  staphylococci,  and  "serosapro- 
phytes"  for  those  which  can  grow  only  in  digested 
albumens.  The  native  albumens  of  human  serum  are 
"protected"  from  bacterial  development  at  their  ex- 
pense, and  Wright  points  out  that,  if  this  were  not  so, 
human  life  would  have  been  impossible.  Among  the 
serosaprophytes  are  the  larger  number  of  the  organ- 
isms found  in  wounds,  including  all  the  anaerobes; 
the  bacillus  of  Welch,  the  bacillus  of  tetanus,  the 


42  AMERICAN  ADDRESSES 

enterococcus,  a  streptococcus  of  intestinal  origin  de- 
scribed by  the  French,  the  bacillus  coli,  and  putre- 
factive bacilli  X  and  Y,  which  are  the  cause  of  the 
foul  odour  often  met  with  in  wounds.  There  is  often 
a  '*wisp"  bacillus,  and  a  diphtheroid  bacillus  appears 
in  later  stages  of  the  infection. 

All  these  microorganisms  find  a  most  fertile  medium 
for  their  growth  in  wounds  of  the  character  I  have 
described.  In  every  anfractuous  wound,  where  the 
recesses  are  many  and  intricate,  blood  or  serum  may 
be  poured  out;  tryptic  digestion  begins  as  a  conse- 
quence of  the  destruction  of  the  leukocytes,  peptones 
are  formed,  and  bacteria,  finding  everything  to  their 
liking,  grow  apace.  From  many  of  the  wound  sur- 
faces the  circulation  has  been  cut  off  by  the  powerful 
stunning  effect  of  the  blow  given  by  the  projectile, 
and  gangrene  and  sloughing  make  haste  to  develop. 
During  the  first  four  to  six,  or  in  some  cases  even 
eight,  hours  few  organisms  or  none  can  be  recovered 
from  the  wounds,  either  by  smear  methods  or  by 
cultural  methods.  The  organisms  are  there,  never- 
theless, and,  given  the  prodigal  fertility  of  the  soil 
in  which  they  are  sown,  will  quickly  show  the  evidence 
of  their  growth.  In  this  brief  early  period  the  wound 
is  said  to  be  "contaminated";  in  all  later  periods, 
"infected."     Against  this  attack  made  upon  it  by 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  43 

immeasurable  millions  of  organisms,  how  does  the 
body  protect  itself?  The  chief  defence  is  in  the  blood- 
serum  and  in  the  leukocytes  (phagocytes).  The 
capacity  of  these  two,  if  only  they  have  an  adequate 
chance,  may  be  said  to  be  almost  illimitable  against 
all  organisms  but  the  streptococcus.  The  serum 
possesses  strong  bactericidal  powers  of  its  own;  the 
phagocytes  can  devour  bacteria  greedily.  But  in 
exerting  their  powers  both  serum  and  white  cells  are 
apt  to  undergo  degradation.  The  leukocyte  breaks 
down  and  its  power  of  tryptic  digestion  is  then  exerted 
upon  the  fluids  around  it,  and  peptones  are  produced 
in  quantities  which  make  easy  the  growth  in  them  of 
all  forms  of  bacteria.  Moreover,  the  surface  of  the 
wound  soon  becomes  "lymph-bound."  A  mesh  of 
fibrin  entangles  the  blood-cells,  and  a  sort  of  matting 
of  coagulated  lymph  spreads  over  all  the  surface. 
No  fresh  serum  can  then  reach  the  wound,  nor  are 
fresh  leukocytes  available  for  the  attack.  The  infec- 
tive process  can  then  proceed  apace,  unhindered  by 
those  powerful  natural  defences  which  for  the  moment 
have  quite  broken  down. 


44  AMERICAN  ADDRESSES 

THE  PRINCIPLES  AND  METHODS  OF  TREATMENT 
OF  GUNSHOT  WOUNDS 

(a)  Primary  Closure 
Every  one  to  whose  lot  it  has  fallen  to  undertake 
the  surgical  treatment  of  wounds  in  this  war  will  agree 
that  the  most  urgent  need  is  to  secure  their  complete 
closure  at  the  earliest  possible  moment.  In  the  early 
hours,  during  the  period  of  "contamination,"  it  is 
now  the  common  practice  to  excise  freely  all  damaged 
and  dead  tissue  if  possible  in  one  piece.  This  requires 
some  skill  and  no  little  practice  to  do  excellently. 
The  most  careful  preparation  of  the  skin  and  the 
parts  around  the  wound  is  a  necessary  antecedent  to 
any  operative  measures.  The  wound,  of  whatever 
type,  is  excised,  together  with  a  wall  not  less  than 
3^^  inch  around  it.  In  order  to  make  certain  that  all 
the  walls  of  the  original  wound  are  excised,  Wilson 
Hey  has  suggested  and  has  long  employed  a  method 
of  staining  with  brilliant  green,  which  is  injected  into 
all  parts  of  the  wound,  and  allowed  to  remain  not 
less  than  two  minutes.  The  staining  of  a  wound  not 
only  makes  a  more  thorough  removal  possible,  but 
it  also  indicates  those  parts  which  cannot  or  may  not 
be  removed,  to  which,  therefore,  a  simple  mechanical 
cleansing  must  be  more  particularly  directed.    When 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  45 

staining  has  been  thought  unnecessary,  he  tells  us  the 
final  results  are  worse.  Staining  in  every  case  is  a 
help :  it  is  never  a  hindrance.  The  walls  of  the  cavity 
remaining  after  excision  should  bleed  everywhere — 
perfect  hsemostasis  is  then  secured.  Every  soiled  in- 
strument or  glove  is  at  once  discarded.  The  wound 
may  then  be  stitched  up  completely  without  drain- 
age, and  with  much  confidence  may  be  expected  to 
heal  well.  The  cases  coming  to  the  base  hospitals  in 
England  show  that  in  a  great  variety  of  injuries  this 
method  of  the  primary  closure  of  wounds  is  meeting 
with  a  very  remarkable  success.  If  the  operation  is 
carried  out  with  scrupulous  exactitude  and  with 
something  near  to  technical  perfection  in  cases  of 
the  smaller  "contaminated"  wounds,  where  there 
is  no  loss  of  substance,  probably  not  less  than  80 
per  cent,  will  heal  by  first  intention.  The  failure 
occurs  in  those  cases  where  a  piecemeal  removal  of 
the  infected  wall  has  been  carried  out,  where,  that  is 
to  say,  there  has  been  a  frequent  reinfection  of  the 
newly  made  raw  surfaces. 

There  has  been  in  all  armies  a  certain  timidity, 
very  natural,  and  perhaps  from  many  points  of  view 
very  desirable,  in  carrying  out  the  method  of  primary 
closure.  No  one  who  has  worked,  even  for  a  brief 
period,  in  the  armies  in  France  can  have  failed  to 


46  AMERICAN  ADDRESSES 

realize  the  desperately  serious  results  which  come 
from  the  injudicious  closure  of  septic  wounds.  Gas 
gangrene,  for  example,  may  develop  in  an  ampu- 
tated stump  if  even  one  stitch  is  put  in  to  approxi- 
mate the  flaps.  And  there  has  consequently  sprung 
up  on  all  sides  a  fear  of  the  premature  closure  of 
wounds.  But  recent  experience  would  seem  to  show 
that,  at  least  in  the  early  cases,  in  cases  reaching  a 
well-equipped  surgical  unit,  say  within  eight  or  ten 
hours,  in  the  period  of  contamination  rather  than  of 
spreading  infection,  a  mechanical  cleansing  of  the 
most  thoroughgoing  kind,  carried  out  ruthlessly  and 
rapidly,  will  allow  the  majority  of  the  cases  to  be 
closed  with  an  excellent  chance  of  primary  union. 
There  can  no  longer  be  any  doubt  that  many  of  the 
cases  which  have  proved  so  successful  under  the 
Carrel-Dakin  method,  applied  during  the  first  six 
to  eight  hours,  would  have  closed  equally  safely, 
and  far  more  rapidly,  under  the  method  of  immediate 
suture;  and  that  consequently  a  certain  degree  of 
suffering  and  much  expenditure  of  time  and  no  little 
expense  would  have  been  saved.  To  put  this  state- 
ment in  what  may  seem  an  extreme  fashion  it  may  be 
said  that  the  Carrel-Dakin  method  has  achieved  its 
greatest  triumphs  in  cases  where  it  need  not  in  fact 
have  been  applied.     But  if  this  opinion  is  true,  it 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  47 

must  at  once  be  admitted  that  one  of  the  chief  ex- 
periences which  have  led  to  its  realization  is  the 
practice  of  this  method,  with  great  success,  during 
many  months,  More  than  ever  are  we  now  con- 
firmed in  our  strong  opinion  that  it  is  the  primary 
mechanical  cleansing,  after  thorough  exposure,  and 
with  every  precaution  and  care,  that  is  the  supreme 
necessity  in  all  cases;  and  that  this  alone,  if  complete, 
will  often  allow  the  natural  defences  of  the  body  to 
secure  the  blameless  healing  of  the  wound. 

(6)  Secondary  Closure 
If,  however,  owing  to  one  or  more  among  a  great 
diversity  of  circumstances,  the  patient  arrives  at  a 
base  hospital  with  a  freely  suppurating  wound,  the 
problem  is  quite  different.  The  chance  of  primary 
closure  has  passed  away  perhaps  long  ago;  the  wound 
now  may  be  covered,  sparsely  or  thickly,  with  sloughs 
of  varying  size  and  in  various  stages  of  detachment. 
Layers  of  lymph  adhere  at  one  point,  or  at  many,  to 
the  wound  surfaces,  and  the  discharges  are  thick, 
purulent,  and  offensive.  The  problem  here  is  first 
to  secure  a  healthy  and  relatively  uninfected  surface, 
and  secondly  to  close  the  wound  by  suture  on  the 
earliest  prudent  occasion.  What  are  the  principles 
which  we  must  now  put  into  practice  .^^    For  purposes 


48  AMERICAN  ADDRESSES 

of  tabulation  and  description  they  may  be  spoken 
of  as  "physiological"  and  "antiseptic,"  though,  as  I 
shall  presently  indicate,  the  difference  between  the 
two  may  not  be  so  sharp  as  such  a  precise  and  limited 
statement  might  appear  to  indicate. 

I.  Physiological  Methods. — ^These  owe  their  origin 
to  Sir  Almroth  Wright.  The  problem  Wright  set 
himself  to  solve,  in  the  case  of  the  septic  "lymph- 
bound"  wound,  was  that  of  rendering  available, 
once  more,  all  the  natural  defensive  mechanisms 
possessed  by  the  body  fluids  and  tissues,  and  of 
exalting  their  power  by  bringing  them  into  play  in 
far  larger  quantities  than  are  usually  at  our  com- 
mand, and  in  a  condition  which,  as  a  result  of  vaccine 
injections,  or  because  of  the  increased  antitryptic 
power  of  blood-serum  of  a  wounded  man,  finds  them 
greatly  augmented.  We  have,  he  says,  to  promote 
the  destruction  of  the  microbes  which  have  been 
carried  into  the  deeper  tissues;  we  have  to  resolve 
the  infiltration  in  the  walls  of  the  wound,  and  to  get 
rid  of  infected  sloughs;  we  have  to  prevent  the  "cor- 
ruption of  the  discharges,"  and  to  inhibit  microbic 
growth  in  the  wound;  we  have  to  be  constantly  on 
our  guard  in  order  to  prevent  those  active  and  passive 
movements  which  propel  bacteria  along  the  lym- 
phatics, and  which  carry  poisonous  bacterial  prod- 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  49 

ucts  into  the  blood;  and  finally,  all  this  being  done, 
we  have  to  get  rid  of  the  surface  infection,  promote 
the  processes  of  repair  in  the  wound,  and  bring  to- 
gether the  wound  surfaces  so  that  they  may  heal. 
How  are  these  various  tasks  successfully  accom- 
plished? 

The  blood  serum,  as  Wright  has  shown,  possesses 
certain  remarkable  properties.  Mechanically  it  is 
the  agent  by  which  phagocytes  are  washed  on  a  ris- 
ing tide  into  the  wound,  and  chemically  it  has  a  power- 
ful bactericidal  efficiency  against  all  microorganisms 
but  the  "serophytes,"  streptococci,  and  staphylo- 
cocci; the  anaerobic  organisms,  that  is  to  say,  are 
destroyed  by  it.  The  phagocytes,  as  Metchnikoff 
long  ago  showed  us,  can  devour  and  digest  micro- 
organisms of  all  kinds,  but,  tried  beyond  a  certain 
point,  they  perish  in  the  fight,  and  liberate  at  their 
death  a  ferment,  trypsin,  which  digests  the  native 
albumens  in  the  serum,  converts  them  into  peptone, 
and  therefore  adds  enormously  to  the  cultural  value 
of  the  wound  discharges.  The  blood,  however,  is 
normally  antitryptic,  and  this  quality  appears  in 
cases  of  infection  to  be  increased;  there  is  an  anti- 
dote, that  is  to  say,  to  the  local  defeat  of  the  phago- 
cytes and  the  consequences  attaching  thereto.  The 
coagulability  of  the  serum  is  also  increased,  with  the 

4 


50  AMERICAN  ADDRESSES 

result  that  a  "felting"  of  fibrin  forms  on  the  walls  of 
the  wounds  and  prevents  the  access  to  the  wound 
of  reinforcements  of  serum  and  of  cells.  Wright's 
method  consists  in  the  application  of  a  "hypertonic" 
solution  of  salt,  5  per  cent,  or  anything  over  that, 
together  with  3^  per  cent,  citrate  of  soda  (this  is  not 
necessary).  The  principle  of  the  hypertonic  method 
is  to  make  use  of  the  bactericidal  power  of  fresh 
serum,  which  is  encouraged  to  flow  from  the  wound 
surfaces  by  the  application  to  them  of  a  more  con- 
centrated saline  solution  than  blood-serum.  A  proc- 
ess of  osmosis  is  at  work.  It  is  argued,  or  rather 
asserted,  which  is  not  the  same  thing,  that  serum  is  a 
fluid  which  will  not  osmose,  but  the  fact  is  indis- 
putable that  when  these  strongly  saline  dressings 
are  applied,  the  discharge  from  all  the  wound  sur- 
faces is  increased  enormously  in  quantity.  The 
patient  is  often  compelled  to  drink  freely,  so  con- 
siderable may  the  drain  of  the  fluid  be.  The  discharge 
from  the  wound  after  the  first  few  hours  becomes  clear 
and  within  three  or  four  days  may  be  found  sterile 
or  of  low  bacterial  content.  The  streptococcus  is  by 
far  the  most  resistant  of  all  microorganisms;  after 
three  to  five  or  six  days  it  is  often  the  only  germ  re- 
maining. As  I  go  around  from  one  hospital  to  another, 
or  from  one  ward  to  another,  I  think  I  am  generally 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  51 

able  to  pick  out  the  cases  which  are  being  dressed  by 
Wright's  solution.  The  granulation  tissues  have  a 
fuller,  deeper  colour,  and  the  surface  looks  cleaner 
than  when  any  other  form  of  dressing  is  being  used. 

The  blood-serum  has  now  done  its  work.  During 
this  time  the  phagocytes  have  been  inhibited  in 
their  action  and  even  destroyed,  as  I  shall  presently 
mention.  It  is  their  aid  which  is,  however,  supremely 
necessary  in  the  attack  upon  the  serophytes.  The 
hypertonic  solution  is  therefore  changed  for  an 
isotonic  solution,  which  encourages  the  migration  of 
leukocytes  and  leaves  them  to  deal  with  the  strepto- 
cocci and  staphylococci  (generally  few  in  number) 
that  alone  remain  in  the  wound.  When  bacteriolog- 
ical examinations  reveal  that  the  wound  is  "clinically 
sterile,"  it  may  be  closed  by  suture  or  its  edges  ap- 
proximated by  strapping. 

The  action  of  hypertonic  saline  solutions  is  com- 
plex, and  its  virtues  are  conflicting.  It  attracts  water 
from  the  blood,  together  with  all  the  protein  sub- 
stances contained  therein;  it  inhibits  leukocytic 
migration,  prevents  phagocytosis,  disintegrates  those 
leukocytes  with  which  it  is  brought  into  direct  con- 
tact, and  thus  sets  free  a  tryptic  ferment  which  di- 
gests the  albumens  of  the  blood-serum.  It  delays 
or  prevents  the  action  of  this  very  ferment  which  it 


52  AMERICAN  ADDRESSES 

has  caused  to  be  liberated.  It  inhibits  coagulation 
and  so  prevents  the  sealing  up  of  the  channels  through 
which  lymph  pours  into  the  wound.  It  appears  de- 
finitely to  inliibit  bacterial  activity  and  propagation. 
Various  modifications  of  Wright's  original  proce- 
dures have  been  made.  Before  I  left  France  for  the 
first  time  in  March,  1915,  we  had  begun  to  use  salt 
tablets,  wrapped  in  gauze,  in  the  wound,  at  the  sug- 
gestion of  Colonel  Lawson,  with  the  intention  of 
keeping  available  in  the  wound  cavity  a  constant 
supply  of  hypertonic  solution.  This  method  was 
afterward  widely  used  and  warmly  advocated  by 
Colonel  Gray  and  Major  Hull,  who  designed  the 
"salt  pack,"  a  most  useful  and  valuable  form  of 
dressing.  After  appropriate  cleansing  a  wound  may 
be  filled  with  a  number  of  salt  packs,  protected  by  a 
few  layers  of  gauze  from  actual  contact  with  the 
granulating  surfaces,  so  as  to  avoid  sloughing,  and 
left  for  eight  or  ten  days.  The  dressing  becomes  very 
offensive;  but  on  its  removal  a  bright,  even,  and 
healthy  layer  of  granulations  covers  every  part  of 
the  wound.  This  method  is  of  great  value  in  many 
cases  of  secondary  haemorrhage  where  only  smaller 
vessels  are  involved ;  and  in  those  cases  where  trans- 
ference of  the  patient  from  one  hospital  to  another  is 
necessary.      Colonel   Sargent  has  recently  used   an 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  53 

ointment  made  of  vaselin  with  5  per  cent,  salt  added 
thereto;  after  a  thorough  cleansing  and  a  sparing 
application  of  this  preparation,  a  secondary  closure 
of  the  wound  will  be  followed  by  healing.  The 
various  papers  of  Sir  A.  Wright  on  "physiological 
methods"  and  on  the  treatment  of  wounds  have 
helped  us  to  realize  better  than  ever  before  the 
immense  complexity  of  the  problems  concerned  with 
the  healing  of  septic  wounds  and  clearly  to  under- 
stand the  principles  upon  which  we  must  rely  in 
order  to  promote  union. 

Antiseptic  Methods. — Before  any  discussion  with 
regard  to  antiseptic  methods  can  be  productive  of 
good  we  must  ask  ourselves  the  question,  "What  is 
it  we  expect  an  antiseptic  to  do  in  an  infected  wound? " 
The  answer  most  commonly  given  by  those  to  whom 
I  put  this  question  is  that  an  antiseptic  acts  by  de- 
stroying bacterial  life.  But  a  great  many  qualifica- 
tions must  be  given  before  such  a  reply  can  receive 
even  a  slender  acquiescence.  The  problem  of  the 
action  of  an  antiseptic  in  an  infected  wound  is  far 
too  complex  for  a  simple  and  ready  answer.  We  know 
in  truth  very  little  even  now  of  what  goes  on  in  all 
parts  of  a  septic  wound.  But  we  may  be  quite  cer- 
tain that  an  antiseptic  is  never  "monotropic,"  en- 
gaging one  substance  only.    It  may  have  an  affinity 


54  AMERICAN  ADDRESSES 

for  the  tissues  forming  the  wall  of  the  wound,  for  the 
serum,  or  for  the  leukocytes;  or  for  any  "corrupt- 
ing" discharges  which  remain  in  the  wound;  or  for 
the  gauze  packed  into  the  cavity  of  the  wound ;  or  for 
the  dressings  applied  to  the  surface.  It  may  have  op- 
posing effect  on  different  parts  of  the  wound;  it  may, 
for  example,  increase  proteolytic  digestion  in  its  ac- 
tion upon  sloughs,  and  it  may  inhibit  or  prevent  this 
process  by  its  effect  upon  leukocytes  and  their  emigra- 
tion. An  antiseptic,  however  potent  in  vitro,  may 
be  quenched  by  the  other  substances  I  have  named 
and  fail  to  influence  the  bacteria  in  any  direct  way. 
Moreover,  the  bactericidal  power  of  an  antiseptic  is 
no  criterion  of  its  penetrative  power.  Its  bactericidal 
power  is  at  once  profoundly  modified  by  its  contact 
with  albumen,  with  which  it  most  eagerly  combines, 
as  is  also  its  power  of  diffusion,  and  therefore  of  reach- 
ing in  a  still  active  condition  all  the  crannies  and 
chinks  among  the  recesses  of  the  wound.  The  direct 
germicidal  effect  of  any  antiseptic  is,  therefore, 
almost  certainly,  very  much  smaller  than  many  of  us 
had  supposed,  and  is  confined  chiefly  or  exclusively 
to  those  bacteria  which  are  lying  bare  to  its  attack 
in  the  open  wound.  I  have,  moreover,  always  thought 
it  very  difficult  to  credit  the  supposition  that  an 
antiseptic,  however  applied,  can  have  an  efficient 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  55 

action  against  microorganisms  in  a  wound  without 
producing  also  a  very  harmful  effect  upon  the  body 
tissues  and  fluids.  Or,  in  other  words,  exclusive  re- 
liance upon  an  antiseptic  to  act  as  a  germicide  is  a 
negation  of  all  dependence  upon  the  principles  of 
physiological  reaction  of  the  tissues  to  a  bacterial 
attack.  These  points  will  emerge  more  clearly  in 
connection  with  a  brief  description  of  the  various 
methods  of  "antiseptic  treatment"  adopted  at  the 
present  time  in  the  zones  of  the  war. 

Among  them  pride  of  place  will  cheerfully  and 
gratefully  be  conceded  to  the  ^' Carrel-Dakin'*  pro- 
cedure. It  consists,  as  all  surgeons  now  know,  of 
a  free  mechanical  exposure  and  cleansing  of  the  whole 
wound.  This  is  so  easy  to  say  and,  alas!  so  diflScult 
in  all  cases  to  carry  out  adequately.  The  wound  so 
made  is  then  lightly  packed  with  gauze  into  which 
a  number  of  Carrel's  tubes  are  laid;  through  these 
tubes  at  intervals  of  about  two  hours  Dakin's  fluid 
is  instilled.  Probably  full  realisation  of  the  need  for 
careful  preparation  and  testing  of  Dakin's  fluid  is 
not  universal;  nor  of  the  rapid  deterioration  in  its 
potency  if  it  is  allowed  to  be  heated,  or  exposed  to 
the  air,  or  stored  in  transparent  glass  bottles  in  warm 
places.  The  method  allows  of  the  early  secondary 
closure  of  wounds,  at  an  average  period  of  eight  to 


56  AMERICAN  ADDRESSES 

twelve  days;  and  coming  when  it  did  before  the  end 
of  the  first  year  of  the  war  it  is  no  exaggeration  to 
describe  its  effects  upon  the  treatment  of  wounds  as 
revohitionary. 

In  what  way  does  the  Carrel-Dakin  method  act? 
Are  its  effects  produced  by  reason  of  the  strongly 
antiseptic  properties  of  Dakin's  fluid,  or  because  of 
other  properties  not  directly  concerned  with  the  kill- 
ing of  microorganisms?  Or  is  the  most  excellent  tech- 
nique for  which  we  cannot  be  too  grateful  to  Carrel 
chiefly  responsible  in  that  it  necessitates  a  greater 
general  care  of  the  wound,  a  free  opening  of  all  re- 
cesses, and  that  constant  supervision  which  detects 
at  the  earliest  moment  any  harmful  development  on 
the  granulating  surface?  If  strict  dependence  is 
placed  upon  the  microbial  curve,  it  would  appear 
that  the  author  of  the  method  believes  that  pro- 
gressive sterilisation  of  the  wound  is  produced  by  the 
chemical  action  of  Dakin's  fluid  upon  the  bacterial 
flora.  The  reduction  in  the  number  of  organisms, 
even  irrespective  of  their  nature,  is  held  to  be  the 
index  of  the  germicidal  effect  of  the  fluid  applied. 
Even  when  comparatively  small  quantities  of  a 
potent  bactericidal  fluid,  like  that  discovered  by 
Dakin,  are  instilled  frequently  into  wound  cavities 
covered   by  sloughs  or  granulations,  the  killing  of 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  57 

microbes  may  not  be  of  serious  consequence.  For 
these  organisms  can  propagate  themselves  at  a  rate 
with  which  the  most  powerful  germicide  could  hardly 
"catch  up"  however  frequently  or  adequately  sup- 
plied. I  can  easily  conceive  of  an  "antiseptic,"  using 
the  word  in  its  clinical  sense,  which  is  not  in  the 
smallest  degree  "germicidal."  I  can  understand, 
that  is  to  say,  that  a  wound,  however  gravely  in- 
fected, may,  by  the  application  of  some  chemical  sub- 
stance, be  deprived  of  its  bacterial  flora,  in  very 
great  measure,  or  even  completely,  though  no  single 
microorganism  is  killed  by  this  substance.  An 
"antiseptic,"  if  not  germicidal  (that  is,  not  acting 
chemically  upon  the  substance  of  which  bacteria  are 
composed) ,  might  yet  render  the  wound  sterile  either 
by  destroying  the  pabulum  of  the  bacteria,  so  that 
they  were  unable  to  flourish  and  to  propagate,  or 
by  exalting  those  normal  powers  of  resistance  pos- 
sessed by  body  tissues  and  fluids,  or  by  holding  up 
the  bacteria  until  those  powers,  without  increase, 
are  capable  of  destroying  or  dispelling  the  infective 
agents.  Or  does  the  action  of  chemical  agents  on  the 
leukocytes  so  alter  their  metabolism  as  to  produce 
substances  which  cause  degenerative  processes  in  the 
bacteria?  That  is,  are  involution  forms  of  bacteria 
developed  by  the  relationship   of  these  agents  to 


58  AMERICAN  ADDRESSES 

them?  The  most  striking  effect  visible  to  the  eye  in 
a  wound  treated  with  Dakin's  solution  is  that  the 
surfaces  are  cleaned  very  rapidly.  Dead  tissue, 
even  large  sloughs,  are  quickly  digested  away,  and 
the  surface  becomes  smooth,  clean,  and  bright  red 
in  colour.  In  a  wound  not  yet  clean  in  all  its  parts 
a  very  different  microbial  curve  can  be  drawn  if 
smears  are  taken  from  the  smooth  red  portion  of  the 
surface  and  from  the  edge  of  a  slough.  It  is  the  dead 
tissue  in  the  wound  that  keeps  the  septic  processes 
going.  If  this  is  destroyed,  bacterial  profusion  and 
virulence  both  rapidly  diminish  until  the  wound  is 
"clinically  sterile."  If,  therefore,  a  substance  could 
be  found  which,  without  having  a  directly  noxious 
effect  upon  bacteria,  could  rid  the  wound  of  all  dead 
tissue  and  allow  the  natural  defensive  mechanism 
to  have  a  free  chance,  it  is  possible  that  the  wounds 
would  heal  as  kindly  as  they  do  under  the  Carrel- 
Dakin  system. 

What  appears  to  be  a  fulfilment  of  this  supposition 
has  been  published  since  the  foregoing  paragraph  was 
written.  Donaldson  and  Joyce*  describe  a  non- 
pathogenic spore-bearing  anaerobe  which  acts,  ap- 
parently in  virtue  of  its  proteolytic  powers,  only  on 
devitalized  tissues,  and  possibly  on  toxalbumins, 
*  Lancet,  1917,  ii,  445. 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  59 

and  appears  to  possess  no  power  of  attacking  healthy 
tissues.  The  powers  of  this  organism  are  directed 
not  only  toward  the  removal  of  the  grossly  damaged 
tissues,  but  it  succeeds  also  in  attacking  the  micro- 
scopically damaged  structures.  As  a  result  the  body 
forces  are  freed  from  the  constant  menace  of  septic 
poisoning  and  are  thus  allowed  to  commence  the 
work  of  repair.  It  is  therefore  an  arguable  proposi- 
tion that  Dakin's  fluid  as  applied  by  the  Carrel 
technic  does  not  act  only  as  a  germicide,  but  also, 
perhaps  chiefly,  as  a  proteolytic  agent,  as  an  agent 
destroying  those  parts  of  the  wound  on  which  alone, 
or  chiefly,  organisms  can  find  a  place  to  propagate. 
It  is,  after  all,  therefore,  the  mechanical  cleansing  of 
the  wound  which  is  of  the  greatest  importance,  and 
the  action  of  Dakin's  fluid  is  perhaps  very  much  the 
same  as  that  of  the  surgeon's  knife  in  these  cases 
where  the  wound  is  excised. 

The  Carrel-Dakin  method  always  stops  short  of 
perfection  in  asepsis.  In  my  experience  the  wound 
is  never  rendered  "sterile"  by  this  method.  Organ- 
isms can  be  found  in  smears  and  developed  in  culture, 
however  long  the  treatment  is  continued  in  a  large 
wound,  a  fact  which  seems  to  me  of  great  significance 
in  relation  to  the  question  of  the  bactericidal  value 
of  Dakin's  fluid.    For  when  fluid  in  the  same  quantity 


60  AMERICAN  ADDRESSES 

as  ever  is  applied,  and  but  few  microorganisms  re- 
main, their  ultimate  annihilation  appears  to  be  im- 
possible. Perfect  sterility,  however,  we  have  long 
known  is  not  necessary  for  a  healing  by  first  intention; 
though  the  quality  of  that  healing  varies  decidedly 
according  to  the  relative  infectivity  of  the  wound. 
The  fewer  and  less  harmful  the  organisms,  the  more 
blameless  is  the  healing.  Surgeons  who  have  worked, 
as  surgeons  should  work,  with  a  bacteriologist  at 
their  elbows,  will  admit  they  have  constantly  closed 
wounds  which  were  proved  to  contain  microorgan- 
isms, and  yet  have  obtained  a  union  of  the  wound  that 
was  good.  Until  I  adopted  my  present  technique  this 
was  a  frequent  experience;  but  many  years  ago  I 
began  (I  was,  I  believe,  the  first  to  begin)  the  cover- 
ing of  the  skin  by  tetra  cloths  which  overlapped  the 
skin  edges,  and  since  then  I  can  be  certain  that  in 
all  clean  cases  the  wound  remains  sterile  to  the  end 
of  the  operation  and  a  flawless  healing  can  be  con- 
fidently expected.  Carrel  has  coined  the  phrase 
"clinical  sterilisation"  to  indicate  that  condition 
in  which  organisms  are  so  few  that  the  wound  can 
safely  be  closed  and  good  healing  obtained.  Regard 
should,  however,  be  paid  not  only  to  the  number  of 
the  microbes,  but  to  their  nature.  I  do  not  like  to 
find  a  streptococcus  present  when  the  day  approaches 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  61 

for  the  secondary  suture  of  a  wound.  Carrel's  method 
must  rely  at  the  last  upon  the  living  properties  of  the 
tissues  to  destroy  or  render  innocuous  the  organisms 
still  remaining  in  the  wound  when  it  is  closed.  It 
is  true  that  they  are  few:  but  they  are  there,  never- 
theless, and  must  be  overcome  if  the  wound  is  to  heal 
and  to  remain  healed.  What  most  surgeons  have 
learned  since  the  introduction  of  this  technique  is 
that  which  those  surgeons  who  worked  in  association 
with  a  bacteriologist  have  long  known,  namely,  that 
infected  wounds  (wounds  "clinically  sterile")  may 
heal  in  a  manner  to  which  the  term  *' first  intention" 
may  without  injustice  be  applied. 

What  are  the  disadvantages  of  the  Carrel-Dakin 
method?  I  often  hear  it  said  that  it  is  a  difficult 
method,  requiring  a  special  training  of  the  surgeon, 
that  it  requires  a  large  amount  of  glass  and  rubber 
tubing,  bottles,  etc.,  that  it  is  costly  in  dressings, 
and  that  it  calls  for  constant  supervision  or  direction 
by  the  surgeon.  There  is  truthfully  no  great  validity 
in  these  objections.  A  special  instruction  of  the  sur- 
geon is  certainly  necessary  if  he  is  to  observe  the 
ritual  carefully,  and  to  understand  what  it  means; 
but  so  it  may  be  said  is  a  special  training  necessary 
for  the  surgeon  when  any  new  technical  procedure  is 
introduced.     The  apparatus  is  cheap,  and  is  easily 


62  AMERICAN  ADDRESSES 

obtained  and  lasts  with  care  for  months.  If  nurses 
are  carefully  trained  to  do  the  dressings  with  punctil- 
ious care,  only  that  supervision  is  needed  from  the 
surgeon  which  he  should  give  to  every  case.  From  a 
military  point  of  view,  however,  it  is  a  difficult  method 
to  practise  on  a  large  scale,  for  in  our  army  we  are 
compelled  to  evacuate  a  large  proportion  of  our  cases 
to  England,  retaining  in  advanced  positions,  or  even 
at  the  base  in  France,  only  those  classes  of  cases  for 
which  movement  has  proved  disastrous.  The  circum- 
stances under  which  Carrel  worked  and  under  which 
he  obtained  his  splendid  results  could  not  conceivably 
be  made  applicable  to  a  whole  army.  Some  part  of  his 
success  must  truthfully  be  attributed  to  his  oppor- 
tunities for  receiving  cases  early  and  for  retaining 
them  for  long  periods. 

The  chief  disadvantage  of  the  method  is  that  if  it 
is  interrupted,  it  fails  lamentably.  When  cases  have 
to  be  transferred  from  France  to  England,  it  may  for 
certain  reasons  be  impossible  to  survey  all  the  cases 
on  board  ship  or  on  the  train;  and  infection  then 
spreads,  and  a  reeking  and  rampant  suppuration  is 
present  when  the  patient  arrives  at  a  base  hospital 
in  England.  This  is,  it  is  true,  an  objection  to  a  par- 
ticular application  of  the  method,  rather  than  to  the 
method  itself.    But  it  is  the  reason,  I  think,  that  the 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  63 

procedure  has  never  found  a  wide  or  general  accep- 
tance in  the  British  army,  though  it  has  many  warm 
advocates,  and  many  who  practise  it  with  a  success 
equal  even  to  that  of  Carrel  or  of  Chutro.  The  chief 
successes  obtained  by  this  method  are  in  the  early 
cases,  in  those  in  which  treatment  can  begin  not 
more  than  six  or  seven  hours  after  the  wound  is  made. 
But  we  are  by  degrees  becoming  less  timorous  in  our 
efforts  at  primary  closure  in  precisely  this  group  and 
our  results  justify  a  wider  acceptance  and  a  more 
general  adoption  of  this  practice.  In  later  cases  the 
Carrel  method  is  beyond  question  a  therapeutic  pro- 
cedure of  the  first  magnitude,  but  it  then  requires 
unwearying  care  and  inexhaustible  patience  and  a 
variety  of  favouring  circumstances  if  the  best  results 
are  to  be  attained. 

In  times  of  leisure  the  method  is  good;  in  times 
of  war,  with  all  the  haste  of  war,  it  will  often  fail. 
"C^est  magnifique,  mais  ce  n'est  pas  la  guerre.'^ 

Rutherford  Morison's  Method. — ^This  method  is 
widely  practised  in  the  base  hospitals  in  England,  and 
by  many  surgeons  is  considered  the  most  satisfactory 
of  all.  The  technique  is  as  follows:  A  wound,  say  of 
the  arm,  leading  down  to  a  compound  comminuted 
fracture  of  the  humerus,  is  freely  opened  up,  after  such 
preparation  of  the  arm  and  of  the  surrounding  parts 


64  AMERICAN  ADDRESSES 

as  is  made  in  all  cases  about  to  undergo  operation. 
The  skin,  that  is  to  say,  is  prepared  with  soap,  anti- 
septic washes  (Morison  uses  1  :  20  carbolic  acid  lo- 
tion), and  spirit.  The  wound  may  be  enlarged  in  any 
direction  in  order  to  make  sure  that  no  recesses  in  it 
remain  undiscovered.  All  granulation  tissue  is  vig- 
ourously  scraped  away  from  the  wound  surfaces; 
bleeding  points  are  secured;  obviously  dead  and  loose 
portions  of  bone,  or  pieces  of  cloth  or  projectiles,  are 
removed.  The  wound  is  packed  with  dry  gauze  for 
a  minute  or  two,  while  towels  about  the  wound  are 
changed  if  necessary,  and  while  the  surgeon  replaces 
all  instruments,  gloves,  etc.,  with  those  freshly  steril- 
ized. The  dry  gauze  is  removed,  the  wound  sponged 
everywhere  with  gauze  moistened  with  methylated 
spirit.  Onto  the  raw  wound  surface  a  thin  layer  of  a 
preparation  known  as  "Bipp"  (bismuth  subnitrate  or 
carbonate  one  part,  iodoform  2  parts,  paraffin  in 
quantity  sufficient  to  make  a  soft  paste).  With  a 
gauze  swab  this  paste  is  rubbed  well  into  the  wound, 
which  is  then  sutured  from  end  to  end  without  drain- 
age. The  arm  is  fixed  on  a  splint  and  the  wound  left 
untouched  for  ten  days.  At  the  end  of  this  period  it 
is  usually  found  healed  or  nearly  so ;  another  dressing 
is  applied,  and  allowed  to  remain  ten  days.  No  fur- 
ther dressing  is  needed.     The  absence  of  frequent 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  65 

dressings  is  an  immense  advantage  and  a  comfort 
beyond  words  to  an  anxious,  overwrought  patient. 

Why  does  Morison's  method  prove  so  successful? 
Is  it  the  free  mechanical  cleansing  of  the  wound  that 
is  of  chief  importance,  or  is  there  some  antiseptic  or 
physiological  virtue  in  the  "Bipp"  as  a  whole,  or  in 
any  of  its  constituent  parts?  It  is  almost  certain  that 
in  the  perfect  mechanical  cleansing  of  the  wound  lies 
the  secret  of  the  method.  For  I  have  treated  wounds 
in  exactly  Morison's  manner  and  have  omitted  the 
paste,  and  have  seen  the  wounds  heal  as  kindly  as 
when  it  was  used.  If  there  is  a  virtue  in  the  paste, 
in  which  of  the  ingredients  does  it  lie?  Probably  in 
the  paraffin  which  produces  that  anaerobic  state  in 
which  healing  can  most  rapidly  take  place.  Mr. 
Morison,  at  my  suggestion,  tried  his  methods  in  two 
cases,  omitting  the  "Bipp,"  and  he  allows  me  to  say 
that  they  healed  as  well  as  the  others  treated  with 
the  paste.  What  disadvantages  attach  to  the  "Bipp" 
method?  There  have  been  several  cases  of  bismuth 
poisoning,  and  I  have  seen  one  of  iodoform  poisoning. 
In  a  certain  number  of  the  wounds,  especially  those 
which  have  been  treated  in  France,  the  paste  has  been 
discharged  in  driblets,  or  in  lumps,  after  the  whole 
wound  has  broken  down.  These  faults  are  due  to  a 
wrongful  application  of  the  method.     Perhaps  less 


66  AMERICAN  ADDRESSES 

than  the  necessary  care  has  been  given  to  the  thor- 
ough opening  of  the  wound,  and  certainly  far  too 
much  of  the  paste  has  been  introduced.  One  writer 
says,  "The  wound  must  be  filled  with  'Bipp'";  that 
instruction  is,  of  course,  the  very  opposite  of  the 
truth.  If  the  paste  is  used  at  all,  only  the  thinnest 
smear  is  applied  to  the  wound  surfaces.  The  excel- 
lent and  indubitable  results  of  Morison's  method 
have  started  once  again  the  quest  of  the  healing  balm. 
All  sorts  of  composite  unguents  and  embalming  ma- 
terials have  been  tried  with  the  hope  of  obtaining  a 
substance  having  an  action  that  may  be  described  as 
a  sustained  push  compared  with  the  "thump"  given 
by  Dakin's  fluid.  A  very  practised  surgeon.  Captain 
Wilson  Hey,  has  used  with  excellent  effect  a  paste 
of  which  boric  acid,  paraffin,  chalk,  and  brilliant  green 
are  the  ingredients,  and  equally  good  results  follow  the 
use  of  pastes  or  powders  containing  chloramin-T  and 
acriflavine.  Many  control  experiments  by  different 
observers  using  the  several  pastes,  or  none,  are  still 
necessary  before  we  can  say  if  any  of  them,  or  any 
parts  of  them,  are  essential  to  an  equal  degree  of  sound 
healing  in  the  wounds.  Recently  what  may  prove 
to  be  the  most  valuable  antiseptic  yet  tried  has  been 
used  in  groups  of  cases  under  the  care  of  a  few  ob- 
servers. This  is  dichloramin  T,  introduced  by  Dr. 
Dakin. 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  67 

Flavine  Compounds. — During  the  last  few  months 
great  interest  has  been  aroused  in  the  surgical  world 
by  the  writings  of  Browning  and  other  workers  in 
the  Bland-Sutton  Institute  of  Pathology  in  praise 
of  flavine  as  an  antiseptic  for  application  to  infected 
wounds.  Browning  claims  that  flavine  compounds 
(proflavine,  acriflavine)  and  brilliant  green  exert  a 
slowly  progressive  bactericidal  action;  in  concen- 
trations which  inhibit  and  finally  kill  bacteria  no 
harmful  effect  upon  the  tissues  or  upon  phagocytosis 
is  produced.  It  is  said  of  the  flavine  compounds  that 
their  bactericidal  potency  is  enhanced  by  the  pres- 
ence of  serum;  brilliant  green,  on  the  other  hand, 
is  reduced  in  activity  by  serum.  The  experiments  of 
Browning  are  criticised  by  Fleming  and  Tanner  and 
others.  Fleming  asserts  that  when  many  microbes 
are  used  in  similar  experiments  to  those  of  Browning 
the  flavine  must  be  in  far  greater  strength  than  that 
given  as  the  *' lethal  concentration,"  in  order  to  effect 
sterilisation;  that  in  a  concentration  of  1:2000 
flavine  completely  inhibits  leukocytic  emigration;  that 
it  has,  if  tested  over  a  period  of  twenty-four  hours, 
a  greater  destructive  effect  on  leukocytes  than  on 
bacteria.  Carrel  has  also  spoken  of  the  weak  anti- 
septic action  of  flavine,  of  its  inefficiency  under  the 
conditions  which  really  obtain  in  wounds,   of  the 


68  AMERICAN  ADDRESSES 

destructive  effect  upon  the  granulations  of  a  wound, 
producing  necrosis,  arresting  cicatrisation,  and  in- 
creasing the  dimensions  of  the  wound  if  used  for  any 
length  of  time.  We  have  had  in  Leeds,  under  the 
direction  of  Major  Braithwaite  and  Lieutenant 
Gruner,  an  experience  of  the  flavine  compounds  ex- 
tending over  many  weeks  and  embracing  a  great 
variety  of  cases,  and  a  trial  of  different  methods  of 
application  has  been  made  (Carrel  technique,  twelve- 
hourly  dressings,  etc.).  The  naked-eye  changes  are: 
An  early  reddening  of  the  surface,  a  considerable 
diminution  of  the  exudate,  a  disappearance  of  the 
fibrinous  deposit,  a  firmer  consistence  of  the  granu- 
lations. If  long  continued,  the  flavine  produces  a 
more  brilliant  red  tinge  in  the  wound,  a  *' beefy" 
look,  and  apparently  all  processes  of  healing  are  held 
in  complete  abeyance. 

The  microscopic  changes  are,  first  of  all,  a  rapid 
fall  in  the  number  of  organisms  per  field,  which  in 
several  cases  is  apt  to  give  place  to  a  secondary  rise 
about  the  fifth  or  sixth  day,  in  the  absence  of  any 
necrosis  of  bone  or  retention  of  clothing  or  missiles. 
Then  a  change  is  found  in  the  character  of  the  cells, 
some  of  which  undergo  cytoplasmic  breakdown  while 
others  show  decided  phagocytic  activity.  Then  this 
activity  ceases  to  be  manifest,  and  the  bulk  of  the 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  69 

leukocytes  undergo  complete  necrosis.  As  the  wound 
improves  in  appearance  so  do  the  cells  become  few 
and  necrotic.  It  is  possible,  Gruner  suggests,  that 
the  flavine  penetrates  into  the  cell  substance  and 
alters  its  metabolism,  setting  up  necrobiosis  along 
abnormal  lines,  with  a  resultant  flooding  of  the  tissues 
with  abnormal  products  of  metabolism.  These  arrest 
the  multiplication  of  the  microbes.  There  may  be 
an  added  inhibition  of  the  outpouring  of  coagulable 
fluids,  causing  the  wound  surface  to  dry  up  after  a 
few  days.  These  changes  appear  to  be  more  rapid 
with  proflavine  than  with  acriflavine.  Many  of  the 
wounds  treated  with  these  compounds  have  been 
closed  by  secondary  suture,  with  results  to  all  ap- 
pearance identical  with  those  which  are  found  after 
treatment  by  the  Carrel  or  Morison  methods. 

Such  is  a  brief  statement  of  the  present  position 
with  regard  to  the  treatment  of  war  wounds.  It  must 
never  be  forgotten  that  the  time  element  is  always 
an  important  factor,  and  that  the  problem  of  dealing 
with  an  early  contaminated  wound  is  not  identical 
with,  indeed,  may  be  marvellously  different  from, 
that  concerned  with  a  lalte  infected  wound.  The  con- 
ditions in  the  early  hours,  when  the  patients  are  at 
the  Casualty  Clearing  Stations  in  France,  are  very 
different  from  those  to  be  combated  when  the  patient 


70  AMERICAN  ADDRESSES 

reaches  a  base  hospital  in  England  after  the  lapse  of 
many  days  or  many  weeks.  Finally  in  the  English 
army,  with  the  channel  and  the  long  train  journey 
interposed  between  the  hospitals  in  France  and  those 
at  home,  a  new  and  very  difficult  set  of  circumstances 
must  be  taken  into  account. 

But  wherever  and  whenever  the  patient  is  seen, 
the  most  urgent  desire  and  the  paramount  concern 
of  the  surgeon  is  to  secure  closure  of  the  wound. 
Whatever  mode  of  dressing  is  adopted,  whatever  pro- 
cedure, whether  of  physiological  or  of  antiseptic  prin- 
ciple, is  trusted,  it  is  the  suture  of  the  wound  at  the 
earliest  opportune  moment  that  must  be  the  goal  of 
every  effort. 

So  far  as  our  present  knowledge  will  allow  us  to 
formulate  conclusions,  the  following  deductions  may 
usefully  be  drawn: 

Perfect  mechanical  cleansing,  that  is,  the  excision 
of  all  contaminated,  infected,  or  dead  parts,  the  re- 
moval of  all  fragments  of  clothing  (by  far  the  most 
important  of  all  causes  of  continuing  infection  in  a 
wound)  and  of  all  projectiles,  is  the  supreme  necessity 
in  all  cases. 

In  early  cases,  when  there  has  been  little  or  no  loss 
of  tissue,  this  may  allow  of  immediate  closure  of  the 


GUNSHOT  WOUNDS  AND  THEIR  TREATMENT  71 

wound,  which  will  be  followed  by  healing  in  the  ma- 
jority of  cases,  say  in  70  per  cent,  or  80  per  cent. 

In  infected  early  cases  the  mechanical  exposure 
and  cleansing  may  be  followed  by  a  treatment  di- 
rected to  the  removal  of  the  remaining  infection. 
Physiological  and  antiseptic  methods  each  have  their 
advocates.  The  aim  of  both  is  to  permit  of  the 
earliest  prudent  secondary  closure  of  the  wound.  In 
infected  late  cases  a  thorough  mechanical  exposure 
and  cleansing  of  the  wound  and  the  parts  around  will 
allow  of  secondary  closure  forthwith  if  certain  anti- 
septic pastes  are  used.  Experience  shows  that  similar 
results  have  sometimes  followed  upon  this  thorough 
mechanical  treatment  of  the  wound  without  the  in- 
troduction of  antiseptics.  A  further  trial  in  this 
class  of  cases  may  show  that  the  natural  defences  of 
the  tissues  already  awakened  are  ample  to  deal  with 
the  infections  then  remaining.  Where  large  gaping 
wounds  are  left  as  a  result  of  gross  destruction  and 
loss  of  tissue,  infection  is  controlled  and  subdued 
without  suppuration  to  the  point  of  "clinical  sterili- 
sation" by  the  application  of  the  Carrel-Dakin 
method. 

It  is  the  natural  defensive  powers  of  the  body  fluids 
and  tissues,  of  serum  and  leukocytes,  that  are  the 
chief  agents  in  finally  subduing  the  bacterial  infec- 


72  AMERICAN  ADDRESSES 

tion  in  a  wound.  Sufficient  reliance  does  not  appear 
to  be  placed  upon  the  stupendous  power  the  body 
tissues  possess  for  controlling  infection. 

Finally,  full  emphasis  must  always  be  laid  on  the 
^paramount  necessity  for  the  complete  immobility  of 
wounded  parts  at  all  times  and  on  all  occasions.  So 
will  one  of  the  most  powerful  agencies  making  for 
reinfection  be  kept  constantly  in  check. 


WOUNDS  OF  THE  KNEE-JOINT 

There  is  probably  no  department  of  surgery  in 
which  greater  changes  have  been  wrought  since  the 
early  days  of  the  war  than  in  that  concerned  with 
the  treatment  of  wounds  of  the  knee-joint.  When  I 
was  first  in  France  in  November,  1914,  the  majority 
of  the  cases  of  wounds  of  this  joint  exhibited,  by  the 
time  that  a  base  hospital  was  reached,  a  grave  sup- 
purative arthritis;  very  often  the  patient  was  ex- 
tremely ill,  with  a  high  temperature  and  all  the  evi- 
dences of  a  severe  constitutional  infection;  and  in 
a  large  number  of  cases  only  the  most  drastic  pro- 
cedures offered  any  hope  that  the  limb  might  at 
least  be  saved.  Too  often,  perhaps,  we  failed  to  re- 
member that  a  man  had  two  legs  and  only  one  life, 
and  conservative  measures  were  pushed  to  excess. 
In  the  work  of  the  French  army,  as  I  saw  it,  amputa- 
tion was  in  such  circumstances  often  advocated  and 
practised  forthwith;  and  there  can  be  no  doubt,  I 
think,  that  though  some  limbs  were  sacrificed  that 
continued  care  might  have  saved,  many  lives  were 
rescued  that  would  otherwise  have  been  jeopardised 
or  lost. 

73 


74  AMERICAN  ADDRESSES 

By  degrees,  however,  as  our  grasp  of  surgical 
principles  grew  firmer,  and  as  transport  facilities 
increased,  cases  were  obtained  earlier,  a  more  direct 
and  deliberate  attack  was  made  upon  the  wounds, 
and  results  began  rapidly  to  improve.  It  was 
quickly  realised  that  all  methods  of  treatment  of 
a  well-established  purulent  arthritis  were  miserably 
inefficient,  and  that  here,  as  elsewhere,  every  effort 
must  be  directed  to  such  a  precocious  and  drastic 
treatment  of  the  wound  as  would  prevent  the  de- 
velopment, never  long  delayed,  of  an  infection.  It 
was  felt  to  be  insufficient  so  to  treat  a  limb  as  to 
save  it  only  with  a  stiff  joint;  the  aims  must  be  both 
to  save  the  member  and  to  preserve  the  freedom  of 
movement  in  the  damaged  articulation. 

For  purpose  of  academic  description  the  following 
classes  of  injury  may  be  recognised: 

1.  Cases  of  Clean  Perforating  Wound  of  the  Knee- 
joint  by  Rifle  Bullet. — There  are  cases  in  which  a  rifle 
bullet  traverses  the  joint  from  side  to  side,  often 
without  inflicting  any  damage  or  the  most  trivial 
damage  to  the  bone.  In  other  cases  the  bullet  or  a 
shrapnel  ball  may  have  entered  the  joint  and  have 
lodged  in  the  lower  end  of  the  femur,  or  in  the  upper 
end  of  the  tibia.  The  wound  or  wounds  inflicted 
may  be  small.    They  are  rapidly  sealed  up,  and  pre- 


WOUNDS  OF  THE  KNEE-JOEsTT  75 

sent  no  evidences  of  inflammatory  reaction.  The 
joint  may  or  may  not  fill  gradually  with  fluid  during 
the  next  few  days.  If  fluid  forms  and  is  removed, 
it  is  commonly  found  to  be  sterile.  In  such  cases 
conservative  methods  are  fully  justified  by  the  re- 
sults. The  joint  must  be  perfectly  immobilised  and 
the  patient  retained  if  possible  at  the  clearing  sta- 
tion, so  as  to  avoid  the  disturbances  often  insepar- 
able from  travel.  Aspiration  of  the  fluid  and  the  in- 
jection of  formalin  and  glycerin,  formerly  often 
practised,  do  not  seem  to  insure  or  to  hasten  the  re- 
covery. 

2.  Cases  of  Penetrating  or  Perforating  Wounds  of 
the  Joint  with  a  Larger  Aperture  of  Entry  or  of  Exit, 
or  Both,  When  the  Projectile  is  Retained  in  the  Joint. 
— ^All  such  cases  must  be  submitted  to  operation. 
The  limb,  which  should  be  immobilised  at  the  field 
ambulance,  is  kept  absolutely  at  rest  until  an  a^-ray 
examination  is  made.  This  is  indispensable;  under 
no  circumstances  may  a  blind  exploration  of  the  joint 
be  made  in  the  hope  that  the  missile,  if  any,  or  if 
many,  may  be  discovered  and  removed.  The  sur- 
geon must  know  beforehand  the  conditions  he  will 
probably  meet,  and  must  deal  with  them  purpose- 
fully and  deftly. 

The  position  and  size  of  the  projectile  being  ascer- 


76  AMERICAN  ADDRESSES 

tained,  the  track  of  the  missile  must  be  determined. 
The  position  of  the  Hmb  as  it  lies  on  the  splint  is,  of 
course,  hardly  likely  to  be  that  which  it  had  when 
the  wound  was  inflicted. 

After  the  whole  limb  has  been  thoroughly  prepared 
in  the  usual  manner,  certain  definite  objects  must  be 
pursued.  The  wounds  and  the  track  of  the  projectile 
must  be  excised;  missiles  must  be  removed,  all  for- 
eign bodies  and  fragments  of  clothing  taken  away, 
and  such  damaged  and  loosened  fragments  of  bone 
sacrificed  as  may  appear  to  be  necessary.  The 
technique  of  wound  excision  is  the  same  in  these  in- 
juries as  in  others;  the  damaged  skin  and  all  the 
bruised  and  lacerated  track  down  to  and  including 
the  synovial  membrane  are  removed,  if  possible,  in 
one  piece.  A  preliminary  sterilisation  of  the  track 
with  the  actual  cautery  is  an  undoubted  advantage. 
How,  precisely,  the  incision  is  to  be  made  will  depend 
upon  the  exact  circumstances.  A  good  rule  for  the 
surgeon  in  all  his  technical  responsibilities  is  that  he 
should  see  well  what  he  is  doing  and  do  well  what  he 
sees.  These  should  be  endeavours  in  the  knee-joint 
especially. 

To  make  a  small  incision,  and  to  introduce  his 
finger  to  "explore"  the  joint,  which  may  mean  to 
grope  blindly  and  clumsily  therein,  is  not  in  accord 


WOUNDS  OF  THE  KNEE-JOINT  77 

with  the  needs  of  eases  such  as  these.  A  quite  ade- 
quate exposure  is  necessary;  if  this  can  be  obtained 
by  an  enlargement  of  the  aperture  of  entrance,  or 
of  exit,  or  of  both,  nothing  more  is  required;  if  it 
cannot,  then  a  long  internal  or  preferably  external 
incision  is  made;  if  these  are  insufficient,  then  the 
surgeon  must  make  up  his  mind  to  a  sacrifice  of  the 
ligamentum  patellae  and  the  making  of  the  semi- 
circular flap  fashioned  in  many  cases  of  excision  of 
the  knee.  By  the  time  the  patient  is  ready  to  use 
his  limb  the  ligament  will  have  united  firmly  and  be 
competent  to  bear  the  strain  then  placed  upon  it. 
There  can  be  no  doubt,  however,  judging  by  the 
cases  I  have  seen,  that  the  functional  result  in  all 
returns  more  slowly  and  always  less  perfectly  than  in 
those  where  only  the  lateral  incisions  are  made.  A 
free  and  full  exposure  of  all  the  injured  parts  being 
then  obtained,  the  following  injunctions  may  be  ob- 
served :  to  remove  all  dead  tissue,  to  remove  all  soiled 
parts,  to  remove  all  foreign  bodies,  clothing,  mud, 
clots,  etc. 

How  strictly  is  the  surgeon  to  interpret  the  rule 
that  all  projectiles  must  be  removed .^^  Our  experi- 
ence in  England  shows  beyond  dispute  that — (a) 
if  a  projectile  is  embedded  in  the  articular  ends  of 
the  bones,  when  the  bone  has  suffered  little  or  no 


78  AMERICAN  ADDRESSES 

damage  beyond  that  necessarily  inflicted  by  the  en- 
trance of  the  foreign  body,  it  becomes  encapsulated 
and  rarely  if  ever  gives  rise  to  subsequent  trouble; 
and  (6)  if  a  projectile,  however  small,  remains  in  the 
knee-joint,  it  is  an  abiding  source  of  infection  and  of 
suppurative  arthritis.  The  most  troublesome  and 
tedious  of  all  the  cases  seen  at  home  are  those  in 
which  a  foreign  body  has  been  left  in  the  joint.  It 
is  therefore  a  strict  and  necessary  injunction  that  all 
projectiles  should  be  removed  at  the  earliest  oppor- 
tunity. All  vessels  bleeding  ever  so  slightly  in  the 
wound  are  carefully  secured.  The  wound  and  all 
parts  exposed  are  gently  wiped,  and  if  the  surgeon 
so  desires,  some  form  of  antiseptic  may  be  used — 
ether,  or  Dakin's  solution,  or  saline  solution.  The 
wound  is  then  closed  by  layer  after  layer  of  catgut 
sutures  until  the  skin  is  reached.  For  this  silkworm- 
gut  is  used. 

Is  drainage  to  be  used.^^  In  the  early  months  of 
the  war  drainage-tubes  were  freely,  indeed  almost 
universally,  employed.  Sir  Anthony  Bowlby,  how- 
ever, had  often  emphasized  their  very  real  disad- 
vantages. Unlike  most  surgeons,  I  believe,  he  had 
for  many  years  in  civil  practice  forbidden  their 
introduction  in  all  cases  under  his  care.  He  has  now 
won  all  opinion  around  to  his  view.    There  can  be 


WOUNDS  OF  THE  KNEE-JOINT  79 

no  longer  any  doubt  that  any  form  of  tube  introduced 
into  the  joint  cavity  in  these  early  cases  is  productive 
of  nothing  but  evil.  Tubes  damage  the  synovial 
membrane  by  their  pressure,  and  are  a  potent  and 
abiding  avenue  of  infection.  As  a  binding  obliga- 
tion, with  no  objections  worthy  of  consideration,  it 
may  be  asserted  that  tubes  should  never  be  placed 
within  the  joint.  It  is  rare  to  see  in  the  base  hospitals 
in  England  a  movable  knee-joint  when  tubes  have 
been  used  within  the  cavity.  Drainage,  however, 
may  be  necessary  and  is  quite  adequately  secured 
by  placing  tubes  ''down  to  but  not  into"  the  joint, 
and  by  leaving  a  gap  in  the  line  of  the  sutured 
synovial  membrane.  The  delicate  tissue  of  the  syno- 
vial membrane  then  suffers  no  harm,  yet  if  effusion 
occurs,  it  finds  a  ready  exit  and  easy  escape  to  the 
surface.  Dressings  are  then  applied  and  absolute 
immobility  secured  for  eight  or  ten  days  by  a  splint. 

There  a^re  cases,  probably  between  10  and  15  per 
cent,  of  the  total  number,  treated  upon  these  lines, 
in  which  an  effusion  into  the  knee-joint,  larger  or 
smaller  in  quantity,  associated  with  an  elevation 
of  temperature,  may  occur,  generally  after  the  fifth 
or  sixth  day. 

What  is  then  to  be  done?  This  question  is  to  be 
answered  by  the  bacteriologist  and  the  surgeon  work- 


80  AMERICAN  ADDRESSES 

ing  together.  An  examination  of  the  fluid  discharged 
from  the  tube,  or  removed  by  aspiration  of  the  joint, 
must  be  made  forthwith.  If  any  organisms  but  the 
streptococcus  or  staphylococcus  are  found,  there  is 
no  need  as  yet  for  anxiety.  In  quite  a  number  of 
the  cases  the  fluid  will  prove  to  be  sterile  and  will 
leak  away  by  slow  degrees  through  the  aperture 
prudently  left  in  the  synovial  membrane.  Day  by 
day  the  temperature  will  fall  and  the  knee  assume 
once  again  its  normal  size,  and  all  will  at  last  go  well. 
If,  however,  the  staphylococcus  is  found,  the  joint 
must  be  watched  almost  from  hour  to  hour.  If 
fluid  is  leaking  away  slowly  and  if  the  temperature 
tends  to  fall,  and  if  the  patient  remains  comfortable, 
then  expectant  methods  may  safely  be  continued. 
In  the  great  majority  of  such  cases  all  anger  will 
subside  and  the  infection  will  be  subdued  by  the 
patient's  own  efforts.  Such  cases  help  one  to  realise 
the  strength  of  the  defensive  power  that  the  knee- 
joint  is  capable  of  exercising.  When,  however,  the 
streptococcus  is  present,  active  and  timely  inter- 
ference is  necessary.  The  joint  must  be  freely  opened 
by  long  lateral  incisions  or  by  semicircular  incisions 
dividing  the  patellar  ligament.  The  synovial  mem- 
brane must  be  stitched  to  the  skin,  and  the  Carrel- 
Dakin  method  adopted.    If  the  infection  is  of  a  still 


WOUNDS  OF  THE  KNEE-JOINT  81 

graver  or  more  hostile  kind,  excision  of  the  joint 
or  even  amputation  may  be  imperatively  necessary. 

There  are  few  types  of  cases,  if,  indeed,  there  are 
any,  which  give  such  genuine  gratification  to  the 
surgeon  practising  in  England  as  those  treated  in 
France  by  methods  similar  to  those  described.  A 
very  large  number  have  now  been  received  into  our 
base  hospitals  in  which,  a  month  or  six  weeks  after 
an  injury  that  two  or  three  years  ago  would  have 
meant  permanent  disablement  of  the  joint  as  the 
best  attainable  result,  all  movements  of  the  knee 
are  free  and  unimpeded  and  attended  by  no  pain 
whatever.  In  no  circumstances  do  we  realise  with 
such  certainty  and  satisfaction  the  remarkable  sci- 
entific advances  made  by  our  colleagues  working 
with  the  army  in  France. 

3.  Cases  of  Perforating  or  Penetrating  Wounds  of 
the  Joint  with  Intra-articular  Fracture. — This  condi- 
tion is  a  degree  more  serious  than  that  in  which  the 
missile  has  cleanly  entered  and  become  firmly  em- 
bedded in  the  end  of  the  femur  or  the  tibia.  There 
is  here  a  shivering  of  the  aHicular  ends,  with  many 
irregular  lines  of  fracture.  In  the  midst  of  a  soft 
mass  of  crushed  bone  the  projectile  may  be  lying. 
All  such  cases  must  be  dealt  with  ruthlessly.  There 
must  be  adequate  exposure  by  one  or  other  of  the 


82  AMERICAN  ADDRESSES 

incisions  before  mentioned;  all  dead,  severely  dam- 
aged, or  entirely  loose  fragments  of  bone  taken  away; 
the  curette  or  the  bone  forceps  being  used  to  get  rid 
of  all  bone  which  is  beyond  hope  of  recovery.  As  a 
rule,  the  distinction  between  sound  and  doomed 
bone  is  easily  made.  The  articular  cartilage  is,  how- 
ever, always  dealt  with  most  sparingly.  The  future 
integrity  of  the  joint  movements  depends  upon  the 
preservation  of  every  undamaged  scrap  of  this 
structure. 

It  will  often  be  found  that  an  injury  which  before 
free  exposure  has  appeared  trivial  is  seen,  when  the 
joint  is  opened  up,  to  be  very  extensive  and  to  require 
a  careful  and  long-continued  toilet  before  all  parts 
are  cleansed  and  removed.  It  may  be  necessary 
once  or  twice  to  change  instruments,  gloves,  or  towels, 
in  the  due  observance  of  the  strict  aseptic  ritual 
always  necessary.  When  all  parts  are  cleaned,  the 
most  perfect  hsemostasis  is  secured  and  the  wound 
then  closed. 

In  many  cases  in  England  we  have  used  Morison's 
paste  (Bipp)  to  smear  over  the  rough  osseous  sur- 
faces which  remain  or  over  a  bruised  or  inflamed 
synovial  membrane.  I  have  seen  several  cases  of 
severe  infection  of  the  knee  treated  by  Mr.  Morison 
himself,  and  have  been  surprised  some  weeks  later 


WOUNDS  OF  THE  KNEE-JOINT  83 

to  see  what  a  remarkable  degree  of  functional  res- 
toration has  been  obtained.  It  is  in  these  severer 
forms  of  injury  to  the  knee-joint  that  we  have  by 
degrees  been  brought  to  realise  that  our  old  timidity 
toward  this  joint  is  quite  needless.  It  is  no  exaggera- 
tion to  say  that  with  proper  care  the  knee  can  pro- 
tect itself  from  infection  almost  as  well,  if  not  quite 
as  well,  as  the  peritoneum.  Our  fear  of  infections 
within  the  joint  was  due  to  an  ignorance  of  the 
methods  of  treatment  of  them.  Most  surgeons  deal- 
ing with  even  a  mild  infection,  and  probably  all  sur- 
geons dealing  with  anything  approaching  a  grave 
infection,  relied  upon  drains  introduced  into  the 
cavity  of  the  joint  to  rid  the  parts  of  inflammatory 
products.  We  know  now  that  nothing  but  harm 
comes  from  a  drainage-tube  placed  into  the  joint. 
If  drainage  is  necessary,  it  is  secured  by  tubes  down 
to  the  synovial  membrane  but  not  within  it,  by 
suturing  the  synovial  membrane  to  the  skin,  or  by 
adopting,  as  Mayo  Robson  suggests,  a  special  pos- 
ture of  the  limb. 

4.  Cases  of  Injury  to  the  Knee-joint,  with  Extensive 
Fracture  of  the  Articular  Ends  of  the  Bones. — The 
practice  to  be  followed  in  such  cases  will  depend 
upon  the  position  and  extent  of  the  injury,  the  num- 
ber and  localisation  of  the  projectiles,  and  the  degree 


84  AMERICAN  ADDRESSES 

of  infection.  If  there  is  extensive  fracture  without 
loss  of  tissue,  it  is  probable  that  an  attempt  to  save 
the  knee  will  be  worth  while;  that  even  if  ankylosis 
results,  the  firmness  and  strength  of  the  limb  will  be 
adequate  to  most  purposes.  When,  however,  there 
is  extensive  localised  loss,  as,  for  example,  when 
one  condyle  of  the  femur  is  blown  completely  away, 
then  a  formal  resection  of  the  knee-joint  forthwith 
is  probably  the  best  course.  In  such  a  case,  even  if 
complete  healing  takes  place,  the  functional  utility 
of  the  limb  is  greatly  hindered  by  those  deformities 
which  inevitably  follow.  As  much  of  the  femur 
must  be  spared,  in  making  the  resection,  as  can  with 
safety  be  left;  the  upper  end  of  the  tibia,  if  intact, 
must  have  only  the  merest  shaving  of  the  articular 
cartilage  excised,  enough,  that  is,  to  allow  a  bony 
ankylosis  to  take  place.  The  amount  of  the  two 
bones  that  can  be  removed  without  serious  disable- 
ment is  remarkable.  I  have  had  one  patient  whose 
leg  was  a  trifle  over  four  inches  shorter  than  the 
other  who  walked  with  vigour  and  not  inelegantly. 
A  part  both  of  the  femur  and  of  the  tibia  had  been 
destroyed  by  a  shell  fire. 

In  cases  included  in  this  group  where  infection  has 
obtained  a  hold  the  method  of  excision  introduced 


WOUNDS  OF  THE  KNEE-JOINT  85 

by  Colonel  FuUerton  may  be  practised.  Instead  of 
bringing  the  opposing  ends  of  the  femur  and  the  tibia 
together,  means  are  taken  by  extension  to  keep  them 
apart.  A  wide  gap  then  is  left  which  may  be  filled 
lightly  with  gauze  and  the  Carrel-Dakin  method  of 
treatment  adopted.  When  the  wound  has  reached 
the  stage  of  "clinical  steriHsation,"  the  bones  may  be 
fitted  together  and  the  limb  fixed  in  a  splint. 

In  still  more  than  severe  types  of  injury  amputa- 
tion of  the  thigh  is  performed  without  delay.  This 
counsel  is  especially  urgent  when  the  great  vessels 
also  are  injured,  when  laceration  of  the  soft  parts  is 
extensive,  and  when  infection,  especially  with  the 
bacillus  of  gas  gangrene,  is  evident. 

CONCLUSIONS 

1.  In  all  cases  of  wounds  of  the  knee-joint  the  limb 
should  be  fixed  immovably  upon  a  splint  at  the 
earliest  possible  moment,  and  until  circumstances 
and  surroundings  permit  of  a  complete  operation. 

2.  At  the  Casualty  Clearing  Station,  or  other  oper- 
ating centre,  an  x-rsiy  examination  is  made  in  all 
cases.  The  whole  limb  is  then  prepared  for  opera- 
tion. 

3.  The  following  are  the  essential  features  in  all 
operations:   excision  of  the  wounds  and  of  the  track 


86  AMERICAN  ADDRESSES 

of  the  projectile  after  preliminary  sterilisation  by  the 
cautery  or  otherwise;  a  free  exposure  of  the  joint, 
either  by  enlarging  existing  incisions  or  by  long  in- 
ternal or  external  incisions  or  by  the  formation  of  a 
flap  by  division  of  the  patellar  ligament. 

4.  All  foreign  bodies  must  be  removed  from  the 
joint.  Even  the  smallest  piece  of  clothing  or  of  metal 
may  be  the  nidus  of  a  continuing  infection. 

5.  The  wounds  are  closed  in  layers  by  catgut  su- 
tures. Drainage  is  secured  by  leaving  a  gap  in  the 
line  of  suture  of  the  synovial  membrane,  or  by  leav- 
ing a  tube  close  "down  to  but  not  into"  the  joint. 

6.  Drainage-tubes  are  never  placed  within  the 
joint  cavity.  They  do  not  drain  the  joint;  they  are 
harmful  in  their  effects  upon  the  delicate  synovial 
membrane,  and  they  are  often  a  channel  by  means 
of  which  infection  is  conducted  to  the  joint. 

7.  In  cases  of  severe  infection  of  the  joint  by 
staphylococcus,  or  especially  by  the  streptococcus, 
the  wounds  must  be  reopened,  the  synovial  membrane 
stitched  to  the  skin,  free  drainage  of  the  joint  secured, 
and  the  Carrel-Dakin  or  other  method  of  progressive 
sterilisation  of  the  wound  adopted.  In  more  severe 
cases,  with  an  infection  rapidly  gaining  ground,  ex- 
cision of  the  joint  may  be  necessary. 


WOUNDS  OF  THE  KNEE-JOINT  87 

8.  In  cases  of  severe  comminution  of  the  articular 
ends  with  much  loss  of  substance  (the  whole  of  one 
condyle,  for  example)  a  resection  of  the  joint  is  per- 
formed forthwith. 

9.  In  severe  and  extensive  wounds  with  heavy  in- 
fection the  method  of  resection  with  wide,  temporary 
separation  of  the  ends  of  the  bones  (Fullerton)  should 
be  practised. 

10.  In  cases  of  very  extensive  damage,  especially 
with  infection,  amputation  is  desirable. 

The  following  record,  made  by  Colonel  Gilbert 
Barling,  C.  B.,  of  the  work  done  at  a  group  of  base 
hospitals  in  France,  though  many  months  old,  may 
still  be  quoted  with  interest : 

1.  Total  cases  of  injury  to  knee  operated 

on 845 

2.  With  bone  injury 438 

3.  Without  bone  injury 407 

4.  Wound  excised  and  closed 322 

5.  Cases  under  (4)  requiring  further  oper- 

ation       82  =  25.5  per  cent. 

6.  Wound  excised  and  packed 336 

7.  Cases  under  (6)  requiring  further  oper- 

ation    128  =  38.4 

8.  Excision  of  knee 42 

9.  Artkrectomy,  partial  or  complete 15 

10.  Excisions  or  arthrectomies  amputated  .     13  =  22.8        " 

11.  Deaths  after  excision  or  arthrectomy  .  .     13  =  22.8        " 

12.  Amputation  without  excision 151 


88  AMERICAN  ADDRESSES 

13.  Deaths  under  class  12 49  =  32.4  per  cent. 

14.  Total  amputations 164  =  19.4 

15.  Total  mortality 72=  8.5 

Note. — One  hospital  with  a  large  number  of  cases  was  un- 
able to  separate  the  cases  under  items  4  and  6. 


ON  INJURIES  TO  THE  PERIPHERAL  NERVES 
AND  THEIR  TREATMENT 

In  the  preparation  of  this  paper  I  have  received  valuable 
help  from  my  colleagues  on  the  staff  of  the  Second  Northern 
General  Hospital,  Leeds,  Captain  Burrow,  Captain  Daw,  Cap- 
tain Richardson,  and  Dr.  Cuthbert  Morton. 

NATURE  OF  INJURIES 

The  lesions  of  nerve-trunks  as  the  result  of  wounds 
inflicted  in  war  may  be  of  diverse  forms : 

I 

In  the  majority  of  cases  the  nerve-trunk  has  not 
sustained  a  primary  injury.  It  may  be  exposed  in 
greater  or  less  degree  in  a  wound  of  the  soft  parts 
with  or  without  fracture.  If  the  wounds  are  gravely 
infected  and  suppuration  occurs  with,  perhaps,  ne- 
crosis of  one  or  of  many  fragments  of  bone,  the  proc- 
ess of  healing  may  be  long  delayed,  and  the  cicatri- 
cial tissue  which  results  will  be  of  exceeding  density. 
The  nerve  then  may  come  to  lie  in  the  midst  of  a 
fibrous  mass  which,  undergoing  progressive  contrac- 
tion, presses  more  and  more  firmly  upon  the  delicate 
and  tender  tissue  of  the  nerve.    The  nerve-trunk  is 

89 


90  AMERICAN  ADDRESSES 

strangled,  bereft  of  its  due  supply  of  blood,  and  be- 
comes in  consequence  functionless.  It  is  impossible 
before  operation  to  decide  in  the  severer  cases  whether 
such  a  nerve  has  or  has  not  been  completely  divided. 

II 

The  nerve-fibres  may  not  have  been  directly,  or 
they  may  have  been  only  very  trivially,  implicated, 
but  the  projectile  may  have  passed  so  near  the  nerve- 
trunk  as  to  have  opened  its  sheath.  The  nerve  then 
becomes  adherent  to  the  track  of  the  missile,  and  a 
mass  of  fibrous  tissue  is  found  firmly  welded  on  to  its 
lateral  aspect.  Or  the  projectile,  in  this  case  a  rifle 
or  machine-gun  bullet,  may  at  that  period  of  its  flight 
when  it  has  become  steady  have  cleaved  through  the 
trunk  of  a  nerve,  separating  the  fibres  and  severing 
few  or  none.  Haemorrhage  within  the  sheath  occurs, 
and  a  fibrous  mass  develops  in  the  centre  of  the  nerve, 
causing  it  to  assume  a  fusiform  appearance.  There 
is,  then,  a  central  neuroma. 

Ill 

The  nerve  may  have  been  partly  severed,  say  in 
half  its  diameter,  by  a  projectile  or  a  fragment  of 
bone.  The  gap  in  the  nerve  is  soon  filled  up  by  fibrous 
tissue,  which  extends  widely  upward  and  downward 


INJURIES  TO  THE  PERIPHERAL  NERVES        91 

and  away  from  the  side  of  the  nerve,  so  that  a  hard 
fibrous  lateral  neuroma  is  found. 

IV 

The  nerve  may  be  completely  severed.  In  such  a 
case  a  gap  of  greater  or  less  length  is  found  between 
the  divided  ends.  Bridging  this  interval  there  may 
be  a  connecting  strand  of  fibrous  tissue,  or  a  blurred 
mass  of  scar  material  in  which  both  cut  ends  are  lost. 
In  some  cases  the  nerve  may  appear  hard  and  swollen, 
and  as  though  its  fibres  were  continuous ;  but  careful 
dissection  will  show  that  there  is  complete  division. 

When  the  nerve  has  been  cut  completely  across,  the 
upper  divided  end  is  soon  found  to  present  a  charac- 
teristic bulbous  appearance.  On  section  this  is  seen 
to  consist  partly  of  fibrous  tissue  and  partly  of  nerve 
tissue.  From  the  upper  end  of  any  divided  nerve  the 
axis-cylinders  grow  downward  tirelessly,  each  one 
searching  out  diligently  but  blindly  the  lower  end  to 
which  it  seeks  to  unite.  When  the  quest  fails  in  one 
direction  and  an  uncongenial  tissue  is  met,  the  axis- 
cylinder  turns  in  another  direction,  searching  there 
fruitlessly  again,  and  so  twists  itself  in  ceaseless  con- 
tortion until  a  tumour — Siterminal  neuroma — ^is  formed. 

The  fibrous  mass,  often  of  extreme  density,  which 
goes  to  the  making  of  the  bulbous  end  is  probably  the 


92  AMERICAN  ADDRESSES 

reply  of  tissues  to  the  contact  of  exposed  nerve-fibres 
with  them.  The  peripheral  nerves  are  intruders 
among  the  other  tissues  of  a  limb,  reaching  them  by  a 
process  of  invasion  from  without.  The  contact  of 
these  nerve-fibres  with  any  other  tissue  is  prevented 
by  their  closure  within  a  sheath  whose  function  ap- 
pears to  be  that  of  an  insulator.  The  end  organs  of 
the  sensory  nerves  may  indeed  be,  as  W.  Trotter 
suggests,  a  special  mechanism  for  isolating  the  nerve- 
fibres,  protecting  them  from  actual  contact  with  the 
tissues.  Whenever  the  nervous  system  is  injured,  by 
accident  or  design,  as  in  the  operations  of  trephining 
and  laminectomy,  there  is  always  a  hasty  and  ade- 
quate attempt  to  isolate  the  parts  again.  There  is  an 
intolerance  of  the  tissues  for  contact  with  nerve 
matter  or,  conversely,  of  these  with  other  tissues. 

Gosset  says  that  the  axis-cylinder  is  very  unintel- 
ligent. I  am  not  sure  that  its  search  for  the  distal 
end  is  stupid  because  it  is  unsuccessful.  The  search 
is  zealous  enough,  but  the  axis-cylinder  shrinks  from 
ignoble  contact  with  a  baser  tissue,  and  turns  aside 
to  seek  elsewhere. 

The  lowered  severed  end  becomes  thickly  covered 
with  a  fibrous  cap  which  forms  a  barrier  impenetrable 
by  the  axis-cylinders  seeking  so  earnestly  to  find  their 
way  along  the  distal  nerve. 


INJURIES  TO  THE  PERIPHERAL  NERVES       93 

1.  THE  NERVES  INJURED;    RELATIVE  FREQUENCY 
The  relative  frequency  of  affected  nerves  has  in  our 
experience  been  as  follows: 

Per  Cent. 

Musculospiral 25 

Ulnar 24 

Median 14 

Sciatic 12 

External  popliteal 12 

Internal  popliteal 1 

Upper  portion  of  the  brachial  plexus 4 

Lower  portion  of  the  brachial  plexus  (cords) 7 

Anterior  crural 1 

This  corresponds  fairly  accurately  to  the  experience 
recorded  by  Gosset  and  by  Tinel. 

2.  DIAGNOSIS 
The  following  points  in  the  clinical  histories  are 
investigated : 

Date  of  injury. 
Nature  of  projectile. 
Position  of  patient  at  moment  of  injury. 
Immediate  effects. 

After-history  (including  history  of  operations  per- 
formed) . 
Physical  examination  consists  in — 

A.  Inspection  of  the  limb  to  note — • 

1.  Attitude,  contractures  (claw  hand,  etc.). 

2.  Position  of  wounds  and  scars. 


94  AMERICAN  ADDRESSES 

B.  Testing  of  the  Efferent  Impulses. 

1.  Motor  weakness  for  paralysis,  each  muscle 
and  each  muscle  group  tested  separately. 

2.  Trophic  and  vasomotor  disturbances.  Non- 
shedding  of  epidermis,  "glossy  skin,"  ulcers, 
changes  in  nails,  etc. 

3.  Changes  in  deep  tissues,  for  example,  muscu- 
lar atrophy,  fibrillation,  bone  decalcification, 
etc. 

C.  Testing  of  the  Afferent  Impulses. 

1.  Pain,  its  character,  distribution,  relation  to 
hot  and  cold  applications  or  weather. 

2.  Loss  of  cutaneous  sensibility,  tested  by  stan- 
dardized stimuli  of  special  instruments  so  that 
results  are  strictly  comparable. 

Light  touch. 

Localisation  of  spot  touched. 

Tactile  discrimination  (pressure,  texture,  etc.). 

Stereognostic  sense  (size  and  shape  of  three 
dimensions);  appreciation  of  compass 
points  applied  simultaneously. 

Thermal  stimuli  (hot  and  cold  test-tubes). 

Painful  stimuli  (pinprick  controlled  by  stan- 
dardized spring). 

Roughness  (Graham  Brown  sesthesiometer). 

3.  Deep  sensibility. 
Pressure  pain. 
Vibration  sense  in  bones. 
Joint  and  muscle  sense,  etc. 


INJURIES  TO  THE  PERIPHERAL  NERVES       95 

Electrodiagnosis 

The  reactions  to  the  interrupted  current  are  tested 
by  shocks  from  an  induction  coil,  the  electrode  being 
placed  upon  the  "mator  point"  of  each  muscle  in 
turn.  The  current  from  a  secondary  coil  is  always 
used. 

A  positive  reaction  to  faradism  is  regarded  as  a 
contraindication  to  operation,  but  failure  to  respond 
gives  no  definite  information,  for  voluntary  move- 
ment may  return,  after  nerve  injury,  before  the 
f  aradic  response. 

The  muscles  are  next  investigated  by  a  constant 
current.  "Polar  changes"  have  been  found  to  be  of 
minor  value;  they  may  vary  with  the  local  circula- 
tory changes  following  massage,  etc.  The  character 
of  the  contraction  is  of  much  more  importance.  A 
brisk  twitch  indicates  the  probable  presence  of  some 
conducting  nerve-fibres  in  the  muscle  tested,  while 
a  slow  "vermicular"  response  is  usuajly  associated 
with  a  complete  interruption  of  nerve-fibres. 

The  nerve  muscle  is  next  examined  by  means  of  a 
condenser  discharge.  The  method  depends  upon  the 
fact  that  a  condenser  discharge  through  a  constant 
resistance  gives  a  current  which  varies  in  duration 
according  to  the  capacity  of  the  condenser  used. 

The  more  severe  the  damage  to  the  nerve,  the 


96  AMERICAN  ADDRESSES 

greater  will  be  the  capacity  of  the  condenser  required 
to  excite  it.  Or,  in  other  words,  the  longer  the  dura- 
tion of  the  current,  the  more  chance  is  there  of  ob- 
taining a  response  in  such  a  nerve  muscle.  The  whole 
advantage  of  the  condenser  method  is  that  a  definite 
measurement  of  current  or  condenser  used  may  be 
noted,  and  future  progress  may  be  accurately  fol- 
lowed. 

The  condenser  method  is  chiefly  used  in  cases 
where  operation  is  deferred  because  some  function 
is  found  to  be  present  in  a  given  injured  nerve.  (The 
work  done  recently  by  E.  D.  Adrian  and  others  shows 
that  the  condenser  is  disappointing  in  practice;  but 
it  nevertheless  gives  useful  information  in  recording 
progress.) 

Complete  absence  both  of  faradic  and  galvanic 
response  is  an  indication  for  early  operation.  The 
cases  which  require  careful  and  repeated  examinations 
are  those  where  there  is  pressure  on  the  nerve-trunk 
by  a  contracting  scar.  In  some  nerve-trunks  there 
is  little  damage  to  some  of  the  fibres,  with  total  loss 
in  others.  Operation  must  not  be  deferred  too  long 
in  these  cases,  because  the  fibres  with  complete  re- 
action of  degeneration  may  never  recover  on  account 
of  a  dense  scar  tissue  formation  at  the  site  of  injury. 
In  other  words,  the  presence  of  a  degree  of  volun- 


INJURIES  TO  THE  PERIPHERAL  NERVES       97 

tary  power  in  some  individual  muscles  of  a  group 
supplied  by  a  damaged  nerve  is  no  sure  criterion 
that  the  paralysed  muscles  will  recover  without 
operation. 

It  is  most  important  that  nerve  injuries  should  be 
reexamined  at  frequent  intervals  and  carefully  de- 
tailed records  of  motor  power,  sensory  changes,  and 
electrical  reactions  kept.  In  this  way  treatment 
may  be  modified  according  to  progress. 

In  operations  upon  nerves  where  a  diagnosis  of 
total  loss  in  some  fibres  only  has  been  made  it  is  our 
practice  to  test  the  exposed  nerve  both  above  and 
below  the  site  of  injury  at  the  time  of  operation. 

For  this  examinaition  special  sterilisable  electrodes 
and  long  connecting  cords  which  can  be  boiled  are 
used.  The  nerve  is  gently  lifted  upon  two  small 
glass  hooks  and  a  very  weak  faradic  current  em- 
ployed. 

The  most  accurate  anatomical  arrangement  of 
fibres  may  be  noted  by  this  means  and  the  knowl- 
edge used  to  secure  perfect  adaptation  in  nerve  suture. 
The  diagnosis  is  often  completed  during  a  period 
in  which  massage,  baths,  and  electrical  treatment  are 
employed  to  improve  the  local  circulation,  and  splint 
treatment  adopted  to  relax  affected  muscle  groups 
and  to  overcome  contractures.    The  distinction  be- 

7 


98  AMERICAN  ADDRESSES 

tween  anatomical  and  physiological  division  is  not 
made  before  operation. 

DIFFICULTIES  IN  DIAGNOSIS 
The  main  difficulties  encountered  in  arriving  at  an 
exact  diagnosis  are  in  cases  where  there  are : 

Wasting  and  stiffness  from  disuse. 

Circulatory  disturbances. 

Contractures. 

Destruction  or  adhesion  of  muscle  and  tendon. 

Operation  is  decided  upon  in  the  following  circum- 
stances : 

1.  In  cases  of  complete  division. 

2.  In  cases  of  incomplete  division,  where  progress 
is  arrested. 

3.  Where  there  is  severe  neuralgic  pain,  "causal- 
gia." 

Operation  is  deferred — 

1.  For  one  month  after  the  closure  of  the  wound 
where  soft  parts  only  are  injured. 

2.  For  two  or  three  months  after  complete  closure 
of  the  wound  where  bone  has  been  involved. 

3.  Definitely  so  long  as  progressive  signs  of  re- 
covery in  nerve  functions  continued. 

The  suture  of  the  nerve  may  have  to  be  delayed 
until  unsatisfactory  joint  conditions  are  improved. 


INJURIES  TO  THE  PERIPHERAL  NERVES       99 

Contractures  of  the  knee,  for  example,  should  be 
corrected  before  the  sciatic  nerve  is  sutured,  other- 
wise the  nerve  would  be  in  danger  of  rupture  if  the 
deformity  were  subsequently  rectified. 

In  other  cases  the  nerve  may  be  sutured  and  the 
joint  dealt  with  at  the  same  period  and  subsequently. 

It  is  of  the  first  importance  to  start  active  measures 
to  prevent  or  remove  stiffness  and  deformity  in  the 
parts  supplied  by  a  wounded  nerve.  This  can  often 
be  done  for  many  weeks  before  it  is  possible  to  repair 
the  nerve.  It  is  not  sufficiently  realised  that  a  nerve 
to  be  of  use  after  suture  must  act  upon  live  and  supple 
tissue.  Joints  and  muscles  must  be  kept  ready  for 
the  nerve  impulse  which  some  day  will  come  to  them 
again. 

OPERATIONS 

When  the  diagnosis  of  a  nerve  lesion  requiring 
operation  has  been  made,  the  earliest  prudent  oc- 
casion must  be  chosen  for  operation.  In  both  the 
French  and  British  armies  nowadays  the  suture  of  a 
divided  nerve  is  performed  in  those  most  advanced 
operating  centres  where  the  first  deliberate  toilet 
of  the  wound  is  possible.  It  is  realised,  of  course, 
that  very  often  a  complete  union  between  the  severed 
ends  cannot  result,  but  even  if  the  operation  prove 
eventually  to  be  a  complete  failure,  the  subsequent 


100  AMERICAN  ADDRESSES 

operative  procedures  are  certainly  easier,  and  it  is 
a  satisfactory  thought  that  a  chance  has  been  given 
for  heaHng  to  take  place. 

In  the  great  majority  of  nerve  lesions  dealt  with 
up  to  recent  times  the  wound  inflicted  by  the  pro- 
jectile has  suppurated.  We  have  learned  by  bitter 
experience  in  this  war  what  this  means.  It  means 
that  the  bacterial  flora  in  such  a  wound  are  numer- 
ous, and  potentially,  at  least,  of  great  malignancy. 
It  means  that  even  a  simple  operation  upon  a  wound 
which  still  discharges  pus  may  arouse  a  flaming  in- 
fection and  be  a  cause  of  tetanus  or  gas  gangrene. 
Mere  passive  movement  of  a  joint  grown  stiff  by 
inactivity  may  bring  about  an  attack  of  tetanus  even 
though  the  adjacent  wound  has  healed.  In  many 
cases  an  injury  to  bone  may  have  been  inflicted  at 
the  same  moment  as  the  division  of  the  nerve;  this 
is,  of  course,  frequently  the  case  when  the  musculo- 
spiral  nerve  is  implicated.  Many  loose  pieces  of 
bone  may  remain  as  sequestra  in  the  wound  and  may 
need  removal  or  may  escape  spontaneously  from  time 
to  time.  In  all  such  cases  operation  upon  the  nerve 
must  be  deferred  until  the  wound  has  been  soundly 
healed  for  some  weeks ;  no  rule  is  more  binding  upon 
the  surgeon  than  that.  During  this  period,  which 
may  be  protracted,  the  most  diligent  attention  must 


INJURIES  TO  THE  PERIPHERAL  NERVES      101 

be  given  to  the  limb,  especially  to  those  parts,  mus- 
cles and  joints,  distal  to  the  injury.  The  paralysed 
muscles  must  be  kept  in  a  position  of  relaxation. 
This  may  be  easy,  as  in  those  cases  where  the  mus- 
culospiral  nerve  is  divided;  it  is  often  difficult,  as 
in  cases  of  injury  to  the  median  nerve;  it  is  some- 
times impossible,  as  in  dual  or  triple  lesions  of  nerve- 
trunks.  But,  difficult  or  easy,  the  best  possible  must 
be  done,  for  the  final  functional  result  in  respect  of 
quality  and  of  rapidity  depends  in  no  small  degree 
upon  the  early  care  of  the  parts  deprived  of  their 
nerve  supply. 

Special  and  unremitting  attention  is  given  to  the 
joints,  which  must  always  be  kept  supple.  It  is  re- 
markable how  quickly  the  fingers,  for  example,  be- 
come so  stiff  that  forced  movement  is  an  agony. 
Every  day,  many  times  a  day,  all  the  paralysed  parts 
must  be  freely  moved  to  their  full  range,  and  the 
patient  must  be  instructed  to  attend  to  this  matter 
unceasingly.  The  most  perfect  nerve  healing  is 
robbed  of  its  value  if,  through  long  disuse,  the  muscles 
whose  innervation  is  restored  have  lost  their  power 
to  act,  and  if  the  joints  are  so  firmly  ankylosed  that 
even  passive  movement  cannot  bend  them  fully. 
The  value  of  these  preliminary  and  preparatory 
measures  cannot  be  overestimated. 


102  AMERICAN  ADDRESSES 

When  the  operation  actually  takes  place  it  is  im- 
portant to  observe  certain  essentials  to  success. 
There  must  be  the  most  perfect  and  scrupulous 
asepsis  and  the  most  gentle  handling.  The  finger 
should  never  be  placed  in  the  wound.  All  dissec- 
tions should  be  carried  out  deftly  and  neatly  with  a 
very  sharp  knife,  in  the  "feather  edge"  method  of 
Crile;  the  most  diligent  care  must  be  taken  never  to 
bruise  the  nerve  by  seizing  it,  however  gently,  in 
forceps.  The  nerve  must  never  be  twisted,  or  torn 
or  stretched,  or  unduly  separated  from  its  bed. 
Other  structures  must  be  dissected  from  the  nerve: 
the  nerve  must  not  be  dissected  from  them.  The 
nerve  must  not  be  stripped  bare  for  too  long  a  dis- 
tance, otherwise  it  will  be  devascularised,  and  re- 
cuperative processes  will  be  slow  or  absent.  The 
wound  as  a  whole,  and  the  nerve  in  particular,  must 
not  be  allowed  to  dry  or  to  be  chilled.  The  most 
dainty  and  precise  movements  are  necessary  through- 
out, and  every  bleeding  point  must  be  thoroughly 
secured.  There  are,  of  course,  the  observances  that 
go  to  make  up  the  ritual  of  every  well-trained  sur- 
geon; their  strict  acceptance  is  more  necessary  here 
than  in  almost  any  other  operation,  if  the  most  rapid 
and  the  most  flawless  recovery  is  to  be  made  certain. 

As  a  rule,  a  tourniquet  is  undesirable,  for  two  rea- 


INJURIES  TO  THE  PERIPHERAL  NERVES      103 

sons.  It  is  possible  to  harm  the  nerve,  or  other  nerves 
in  the  Hmb,  if  the  rubber  band  is  apphed  too  tightly, 
and  for  the  long  period  sometimes  necessary  in  this 
procedure;  and  when  the  operation  is  complete  and 
the  tourniquet  removed,  there  will  probably  be  an 
escape  of  blood  into  the  wound — a  thing  in  these 
cases  most  undesirable.  In  these  wounds  not  in- 
frequently there  is  a  good  deal  of  young  fibrous  tissue, 
from  which  free  oozing  may  occur  in  the  period  of 
hypersemia  which  follows  removal  of  a  tourniquet. 

The  incision  is  designed  to  fall  on  the  skin  at  some 
distance  from  the  original  wound  if  possible;  very 
often  a  flap  will  occur  from  the  making  of  a  curved 
incision.  The  planning  of  the  incision  gives  scope 
for  one's  knowledge  of  anatomy;  it  is  so  arranged 
that  no  small  nerves  are  wounded.  Major  Jamieson 
has  shown  that  when  the  median  nerve  is  injured  in 
the  forearm  it  may  sometimes  be  more  thoroughly 
and  successfully  dealt  with  from  the  outer  instead 
of  from  the  inner  side  of  the  flexor  carpi  radialis. 
So,  too,  when  the  musculospirail  nerve  has  been  in- 
jured high  up  on  the  outer  side  of  the  forearm.  Dr. 
Cuthbert  Morton  suggests  that  instead  of  cutting 
through  the  outer  head  of  the  triceps  it  should  be  re- 
flected complete  from  the  humerus.  Not  only  does 
this  cause  less  damage  to  the  muscle  tissue,  but  it 


104  AMERICAN  ADDRESSES 

also  exposes  the  nerve  and  its  branches,  as  well  as 
the  profunda  artery,  to  a  very  high  level  without 
undue  risk. 

The  nerve-trunk  is  sought  above  and  below  the 
point  of  severance,  and  is  traced  downward  and  up- 
ward to  the  gap.  Swift,  neat  little  cuts  with  a  very 
sharp  scalpel  damage  the  tissue  to  the  smallest  pos- 
sible degree.  The  surgeon  must  avoid  contact  of 
his  fingers  with  the  wound:  it  is  clumsy  and  inar- 
tistic to  prod  about  among  muscles  in  the  hope  of 
feeling  the  nerve.  It  is  his  business  to  know  before 
he  begins  these  operations  exactly  where  the  nerve 
lies,  and  he  should  always  be  able  to  cut  directly 
down  on  it.  When  the  injured  part  of  the  nerve  is 
exposed,  it  is  usual  to  find  a  bridge  of  fibrous  tissue 
between  the  ends,  the  proximal  end  being  often  very 
turgid  and  bulbous.  If  the  gap  between  the  refreshed 
ends  of  the  nerve  is  likely  to  be  wide,  now  is  the  time 
for  stretching  the  nerve,  so  as  to  lessen  the  interval 
as  much  as  possible.  This  is  done  with  infinite  gentle- 
ness and  care  by  seizing  the  fibrous  band  between  the 
ends  and  drawing  steadily  upward  and  downward, 
always  remembering  to  make  the  pull  in  the  line  of 
the  nerve-trunk  and  to  avoid  twisting.  The  fibrous 
band  is  now  split  longitudinally,  and  then  its  ends 
are  divided  above  in  one  direction,  below  in  the 


INJURIES  TO  THE  PERIPHERAL  NERVES      105 

Other,  so  that  to  each  cut  end  of  nerve  a  fibrous  tag 
is  attached,  by  means  of  which  the  nerve-ends  can  be 
drawn  together.  Progressive  transverse  cuts  are  now 
made  into  the  nerve-ends  until  on  the  cross-section 
nothing  but  nerve-fibres  are  seen.  Every  tiniest 
particle  of  fibrous  tissue  must  be  removed  or  the 
operation  will  fail.  The  axis-cylinders  coming  from 
above  must  have  free  entry  into  the  nerve  below, 
otherwise  in  their  downward  development  they  will 
lose  their  way,  and  restoration  of  the  nerve  function 
will  not  take  place.  When  the  nerve-ends  are  duly 
prepared,  they  are  brought  into  apposition  with  the 
greatest  care.  A  series  of  very  fine  catgut  sutures 
holding  only  the  nerve-sheath  are  inserted  at  inter- 
vals around  the  circumference  of  the  nerve.  A  suture 
is  never  passed  through  the  substance  of  the  nerve 
itself.  In  uniting  the  nerve-ends  it  is  of  the  first  im- 
portance to  avoid  axial  rotation.  We  know  now  that 
there  is  a  differentiation  of  function  within  each 
nerve,  and  it  is,  therefore,  strictly  necessary  to  unite 
corresponding  bundles  of  fibres.  A  nerve  does  not 
act  as  a  whole,  but  consists  of  a  multitude  of  strands 
each  with  its  proper  and  restricted  function.  Unless 
nerve  bundles  which  were  originally  continuous  are 
brought  accurately  together  by  suture,  the  nerve  is 
compelled  to  rearrange  the  functions  of  its  several 


106  AMERICAN  ADDRESSES 

parts.  This  it  can  and  no  doubt  frequently  has  to 
do.  An  examination  of  manj^  cases  shows,  however, 
that  a  perfect  and  flawless  recovery  after  a  nerve 
suture  is  unusual,  and  it  is  at  least  a  tenable  belief 
that  this  inadequacy  or  delay  in  recovery  is  due  to  a 
want  of  recognition  by  the  surgeon  of  all  that  is 
needed  in  the  technical  part  of  the  operation.  My 
colleagues  on  the  staff  of  the  Second  Northern  Gen- 
eral Hospital  in  Leeds  are  obtaining  results  which  in 
rapidity  and  completeness  would  have  been  thought 
impossible  before  the  war. 

There  is  rarely  any  difficult}^  in  obtaining  accuracy 
of  apposition  without  tension.  If,  however,  the  nerve- 
ends  cannot  readily  be  brought  together,  various 
procedures  may  be  adopted  to  shorten  the  course  of 
the  nerve.  The  nerve  may  be  dislocated  from  its 
bed  and  laid  in  a  new  and  shorter  line.  The  ulnar 
nerve,  for  example,  may  be  brought  to  the  front  of 
the  inner  condyle.  Or  flexion  of  the  limb  may  be 
enough  to  allow  of  easy  approximation.  In  the  case 
of  the  median  nerve  divided  low  in  the  forearm, 
flexion  of  the  wrist  will  give  an  inch  or  more  addi- 
tional reach.  In  other  cases  the  limb  may  be  short- 
ened by  removing  an  inch  or  two  of  bone.  It  is  de- 
sirable to  avoid  a  subcutaneous  course  in  all  trans- 
ferences to  new  positions.     The  nerve  after  suture 


INJURIES  TO  THE  PERIPHERAL  NERVES      107 

should  be  brought  to  lie  in  a  bed  of  healthy  tissue. 
It  must  be  placed  between  muscles,  and  away  from 
all  contact  with  new  connective  tissue,  which  will 
adhere  to  it  and  hinder  its  union,  or  cripple  its  sub- 
sequent action. 

It  has  been  the  fashion  with  many  surgeons  to  sur- 
round the  sutured  nerve  with  some  material  supposed 
to  have  protective  virtues.  A  piece  of  a  vein — the 
saphenous,  for  example— is  threaded  over  the  upper 
cut  end  of  the  nerve  before  suture,  and  after  these 
ends  are  approximated  the  vein  is  drawn  downward 
and  made  to  surround  the  line  of  suture.  In  other 
cases  a  piece  of  fat  dissected  from  near  the  wound, 
or  from  another  part,  is  wrapped  around  the  nerve, 
fat  being  supposed  to  be  capable  of  insulating  the 
nerve  in  its  new  position,  or  a  layer  of  fascia  may  be 
used,  or  a  piece  of  Cargile  membrane.  The  value  of 
all  such  methods  is  open  to  serious  question;  it  is 
certain  that  they  are  sometimes  harmful :  it  is  doubt- 
ful if  they  ever  help.  They  prevent  access  of  blood 
to  the  nerve  by  new  channels;  they  cause  adhesions 
and  compression  of  the  nerve,  and  at  times  they  are 
discharged  from  the  wound  almost  unaltered.  It  is 
better  to  avoid  such  membranes,  and  to  be  content 
with  insuring  that  the  nerve  is  laid  along  the  path  of 
uninjured  tissues.     Where  end-to-end  suture  is  im- 


108  AMERICAN  ADDRESSES 

possible,  a  variety  of  other  procedures  may  be  at- 
tempted. A  nerve  graft,  taken  from  a  neighbouring 
cutaneous  nerve — from  the  radial,  the  internal  cuta- 
neous of  the  thigh,  or  an  intercostal  nerve — may  be 
used.  Experience  on  the  human  subject  has  not  yet 
enabled  me  to  determine  the  value  of  this  procedure. 
In  experimental  work  it  answers  well,  but  I  have 
rarely,  if  ever,  seen  a  result  which  could  be  claimed 
as  satisfactory.  Colonel  Mayo-Robson  has  had  one 
of  the  very  few  successful  cases.*  Nerve  anastomosis 
has  been  tried  in  a  number  of  cases.  The  divided 
ends  of  a  nerve  are  implanted  into  the  side  of  a  near- 
lying  nerve,  the  ulnar  into  the  median,  for  example. 
This  has  been  done  both  with  and  without  section  of 
the  nerve-fibres  of  the  intact  nerve.  All  such  proce- 
dures are  worthless,  and  cannot  be  too  strongly  con- 
demned. I  have  never  seen  any  good  come  of  them; 
indeed,  nothing  but  harm  could  conceivably  result 
from  section  of  a  healthy  nerve.  And  if  it  is  allowed, 
as  it  must  be,  that  a  nerve  consists  of  many  separate 
strands,  each  with  its  own  special  and  exclusive  func- 
tion, it  is  certain  that  permanent  damage  is  inflicted 
by  this  method.  There  is  no  justification  for  this 
procedure  nowadays,  and  it  should  be  cast  out  among 
forgotten  things.  Lengthening  of  the  nerve  by  turn- 
*  British  Medical  Journal,  1917,  i,  p.  117. 


INJURIES  TO  THE  PERIPHERAL  NERVES       109 

ing  down  a  strand  from  the  upper  divided  end  and  the 
bridging  of  the  gap  by  strands  of  catgut,  are  methods 
with  nothing  whatever  to  recommend  and  everything 
to  discredit  them. 

Happily  the  resources  of  surgery  are  not  at  an  end 
in  all  cases  where  union  of  divided  nerves  is  impos- 
sible. Tendon  transplantation,  especially  in  the  case 
of  the  musculospiral  nerve  and  the  posterior  interos- 
seous, gives  results  which,  in  point  of  function,  are 
almost  as  good  as  those  which  come  from  nerve  su- 
ture, and  in  point  of  time  are  much  quicker.  It  is 
chiefly  in  the  musculospiral  nerve  that  large  gaps  are 
found,  a  piece  of  the  nerve  having  been  blown  com- 
pletely away.  In  such  cases  tendon  transplantation 
gives  excellent  and  speedy  results.  When  the  pos- 
terior interosseous  nerve  is  wounded  it  is  not  worth 
while  attempting  to  suture  the  nerve.  The  results 
in  such  cases  are  slow,  and  not  always  perfect. 

In  those  cases  where  the  nerve  is  partly  divided, 
strands  of  intact  fibres  still  remaining,  the  severed 
fibres  are  united  in  the  same  careful  way,  and  the 
normal  strand  of  the  nerve  bent  upon  itself,  so  as  to 
allow  easy  approximation  of  the  cut  portions  of  the 
nerve.  In  perhaps  the  majority  of  operations  upon 
nerves  there  is  no  division  of  fibres,  but  a  length  of 
the  nerve  is  embedded  in  dense  fibrous  tissue.    These 


110  AMERICAN  ADDRESSES 

cases  give  most  excellent  results.  The  fibrous  tissue 
which  so  intimately  surrounds  the  nerve  is  dissected 
away  little  by  little.  The  nerve  when  first  freed  is 
seen  to  be  white  and  shrunken;  but  within  a  few 
minutes  it  expands  and  takes  on  its  normal  colour. 
I  had  several  cases  of  this  kind  in  the  Boer  war,  and 
the  results  at  this  long  interval  are  perfect.  It  is  in 
these  cases  that  advantage  may  sometimes  be  taken 
of  the  method  of  fat  transplantation  or  of  nerve  dis- 
location. 

AFTER-TREATMENT 

1.  Postural 
In  cases  where  flexion  of  a  joint  has  been  necessary 
to  allow  approximation  of  the  cut  ends  of  nerves,  the 
position  is  maintained  for  a  period  of  six  weeks.  By 
this  time  union  of  the  severed  ends  is  probably  well 
advanced.  Extension  by  slow  and  most  cautious 
degrees  is  then  begun.  If  the  knee  has  been  flexed  to 
allow  the  sciatic  nerve  to  be  united,  the  patient  can 
walk  with  a  boot  and  leg  irons,  keeping  the  position 
unaltered  for,  say,  two  months.  Wherever  possible 
a  splint  is  applied  which  produces  a  "relaxation  posi- 
tion." In  the  case  of  the  median  and  ulnar  this  is 
difficult,  and  is  best,  secured  by  molding  a  "ball 
splint"  to  the  hand  of  the  patient.  Every  such  splint 
must  be  made  for  the  individual.    In  the  case  of  the 


INJURIES  TO  THE  PERIPHERAL  NERVES      111 

musculospiral  it  is  very  simple.  The  "cock-up" 
splint  designed  by  Colonel  Sir  Robert  Jones  is  excel- 
lent if  the  lesion  of  the  nerve  is  below  the  branch  to 
the  supinators.  It  maintains  hyperextension  of  the 
wrist,  and,  reaching  only  to  the  heads  of  the  meta- 
carpal bone,  it  allows  a  forward  bend  of  the  meta- 
carpophalangeal articulations.  The  thumb  lies  for- 
ward and  a  little  inward,  so  that  the  position  of  the 
whole  hand  is  very  much  that  assumed  when  a  bottle 
is  grasped.  If  the  lesion  is  above  the  nerve  to  the 
supinator  brevis,  it  is  essential  that  this  muscle  also 
should  be  relaxed.  For  this  purpose  Dr.  Cuthbert 
Morton  has  devised  a  splint  which  retains  the  fore- 
arm and  hand  in  supination  while  the  wrist  is  fully 
extended,  the  fingers  being  at  the  same  time  kept  in 
the  bottle-grasping  position. 

Similarly  in  cases  of  injury  to  the  external  popliteal 
nerve  relaxation  of  the  corresponding  muscles  may 
be  secured  by  the  boot  which  ha^  been  introduced  by 
Dr.  Cuthbert  Morton  in  order  to  allow  the  patient 
to  walk  about  with  the  foot  in  permanent  dorsi- 
flexion. 

2.  Massage  and  Electrical  Treatment 
These  measures  are  restarted  about  two  weeks  after 
operation  with  all  due  precautions  and  safeguards.    If 


112  AMERICAN  ADDRESSES 

a  splint  has  been  applied  to  secure  the  "relaxation 
position,"  it  must  not  be  removed.  Indeed,  not  for 
one  moment  at  any  time  must  paralysed  muscles  be 
stretched.  An  overstretching  of  a  few  minutes  may 
call  for  diligent  treatment  of  many  weeks  before  the 
harm  is  undone.  If  a  splint  needs  removal  for  pur- 
poses of  cleanliness,  the  patient  must  be  instructed 
beforehand  to  kqep  the  limb  in  the  exact  position 
required.  In  the  case  of  musculospiral  palsies  the 
hand  drops  into  the  correct  position  if  the  flexor  sur- 
face of  the  forearm  is  upward. 

RESULTS 
Our  records  are  as  yet  necessarily  incomplete.  Re- 
covery in  the  case  of  the  musculospiral  has  begun 
within  nine  weeks;  in  the  case  of  the  ulnar  within 
three  and  a  half  months;  in  the  case  of  the  median  in 
about  four  to  five  months.  In  one  case  of  division 
of  the  inner  cord  of  the  brachial  plexus  recovery  in 
all  ansesthetic  areas  and  a  degree  of  recovery  in  all 
muscles  occurred  within  five  months.  Recovery  in 
the  case  of  the  sciatic  nerve  is  slower.  Something 
depends,  it  is  sometimes  said,  upon  the  length  of 
time  elapsing  between  division  of  the  nerve  and  its 
suture.  My  colleague.  Captain  Richardson,  has,  how- 
ever, united  the  ends  of  an  ulnar  nerve  cut  across 


INJURIES  TO  THE  PERIPHERAL  NERVES      113 

fifteen  years  before  and  signs  of  returning  function 
were  seen  in  about  four  months.  The  duration  of  the 
disability  is,  therefore,  no  bar  to  successful  repair  of 
the  nerve. 

The  functions  return  usually  in  the  following  order: 

1.  Trophic  and  vasomotor  function. 

2.  Deep  sensibility. 

3.  Tactile  discrimination  and  localization. 

4.  Motor  power. 

5.  Cotton- wool  sensation. 

Perfect  restoration  of  function  has  been  most  nearly 
approached  in  the  case  of  the  musculospiral  nerve. 
In  other  nerves  with  more  complex  distribution  per- 
fect recovery  will  depend  upon  a  recognition  of  the 
functional  localization  within  the  nerve-trunk,  in  ad- 
dition to  the  most  scrupulous  observance  of  all  those 
technical  details  without  which  there  will  always  be 
something  less  than  perfection. 

In  the  diagnosis  and  treatment  of  an  organic  lesion 
of  a  nerve  it  should  never  be  forgotten  that  there  may 
be  superadded  a  functional  disability.  It  is  advisable 
at  every  stage  to  get  rid  of  the  functional  in  order 
properly  to  appreciate  the  organic.  This  is  particu- 
larly important  when  the  organic  lesion  is  well  on 
the  way  to  recovery.  Thus,  in  a  recovering  lesion  of 
the  inner  cord  of  the  brachial  plexus  it  may  be  im- 


114  AMERICAN  ADDRESSES 

possible  for  the  fingers  to  be  flexed  until  reeducation 
has  trained  the  laggard  muscles  into  obeying  orders 
from  headquarters. 

SUMMARY 

The  following  summary  may  be  given  of  our  ex- 
perience up  to  the  present  time: 

1.  The  earliest  examination  should  be  made  of  all 
wounds  in  which  division  of  a  nerve-trunk  is  prob- 
able. If  at  the  Casualty  Clearing  Station  such  a 
lesion  is  found,  end-to-end  suture  should  be  adopted 
forthwith.  This  is  more  likely  to  be  possible  in  cases 
where  primary  suture  of  the  wound,  after  excision, 
is  found  practicable. 

2.  If  secondary  suture  of  the  wounds,  after  the 
Carrel-Dakin  method  has  been  practised,  is  to  be 
undertaken,  the  union  of  divided  nerves  should  be 
secured  at  the  same  time. 

3.  If  these  methods  have  been  attempted  and  have 
failed,  they  do  not  prejudice  the  later  union  of  the 
nerve.  On  the  contrary,  they  probably  insure  that 
an  easier  and  more  satisfactory  operation  can  then 
be  practised. 

4.  Throughout  the  whole  period  before  late  nerve 
suture  is  attempted  the  strictest  attention  must  be 
paid  to  the  relaxation  and  nutrition  of  all  paralysed 


INJURIES  TO  THE  PERIPHERAL  NERVES     115 

muscles,  to  the  maintenance  of  suppleness  in  all 
joints  moved  by  these  muscles,  and  to  the  preser- 
vation of  the  integrity  of  the  skin. 

5.  Operations  upon  nerve-trunks  demand  the  most 
scrupulous  observance  of  the  ritual  of  asepsis.  There 
must  be  the  greatest  gentleness  of  manipulation;  the 
nerve  must  not  be  injured  by  instruments  or  by  the 
surgeon's  finger;  it  must  not  be  separated  from  its 
sheath  or  disturbed  overmuch  from  its  bed;  it  must 
not  be  chilled  or  allowed  to  dry.  All  sutures  must  be 
of  fine  catgut,  and  introduced  with  most  punctilious 
accuracy.  Axial  rotation  of  the  nerve  must  be 
avoided.  The  cut  ends  of  the  nerve  before  approxi- 
mation must  show  clearly  the  fibres  of  which  the  trunk 
consists. 

6.  Nerve-grafting  is  of  little  or  no  value;  nerve 
anastomosis  is  to  be  sharply  condemned;  the  turning 
down  of  flaps  from  the  nerve  to  bridge  a  wide  gap  is 
useless. 

7.  Tendon  transplantation  is  of  great  value  in  cases 
where  nerve  suture  is  impossible,  or  has  given  a  re- 
sult not  entirely  satisfactory. 


GUNSHOT  WOUNDS  OF  THE  LUNGS  AND 
PLEURA 

The  mortality  of  chest  wounds  In  all  zones  of  the 
army  is  extremely  difficult  to  ascertain  with  any- 
thing approaching  accuracy.  Pierre  Duval,  whose 
work  on  the  surgery  of  the  lungs  during  this  war  has 
been  characterised  by  originality,  insight,  prudent 
courage,  and  great  technical  success,  has  gathered 
together  the  records  from  many  points  of  the  French 
army.  Of  a  total  of  3455  cases,  there  were  688 
deaths — roughly,  a  mortality  of  20  per  cent.  But  the 
mortality  differs,  as  may  well  be  imagined,  at  vari- 
ous parts  of  the  line  of  communications.  At  the  aid 
posts  it  is  terrible — ^not  less,  it  is  asserted,  than  25 
to  30  per  cent.  At  the  ambulance  chirurgical  auto- 
mobile, or  Casualty  Clearing  Stations,  the  mortality 
is  about  18  to  20  per  cent.  In  the  base  hospitals 
the  death-rate  is  about  10  per  cent.  There  is,  it  will 
be  seen,  a  progressive  diminution  in  mortality  from 
the  front  to  the  base.  P.  Duval  scrutinized  these 
figures  in  the  following  remarkable  way : 

At  the  aid  post,  where  the  mortality  is  25  per  cent., 

117 


118  AMERICAN  ADDRESSES 

there  will  remain  alive,  of  100  patients,  75.  At  the 
ambulance,  of  these  75,  20  per  cent,  will  die  and  there 
will  remain  60  patients.  At  the  base  of  these  60, 
10  per  cent,  will  die,  so  that  finally  54  cases  will 
survive. 

Two  series  of  cases  falling  under  individual  ob- 
servation may  be  quoted.  Gregoire  records  a  total 
of  404  cases  of  chest  wounds,  pure  and  simple,  with 
47  deaths — a  death-rate  of  11.7  per  cent.  Of  these, 
57  patients  were  operated  upon  for  empyema,  with 
resection  of  the  rib  and  drainage;  26  died — a  mor- 
tality of  45  per  cent. 

Depage,  at  his  well-known  hospital  at  La  Panne, 
which  combines  the  functions  of  Field  ambulance. 
Casualty  Clearing  Station,  and  Base  Hospital,  re- 
ceiving patients  a  few  hours  after  injury  and  retain- 
ing them  as  long  as  is  necessary,  records  320  cases  of 
pure  chest  injury  with  59  deaths,  that  is,  18.4  per 
cent.  Within  the  first  twenty -four  hours  9.4  per 
cent,  of  cases  died,  chiefly  from  haemorrhage.  In  the 
later  stages  10  per  cent,  of  the  survivors  died,  chiefly 
from  sepsis. 

Elliott*  estimates  the  mortality  of  chest  wounds  in 
the  British  army  in  France,  at  the  field  ambulances, 
and  Casualty  Clearing  Stations  at  from  20  per  cent. 
♦Lancet,  1917,  ii,  371. 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA   119 

to  25  per  cent.,  of  which  10  per  cent,  to  15  per  cent, 
are  the  early  result  of  shock  and  haemorrhage,  and  of 
which  10  per  cent,  die  of  sepsis.  The  mortality  on  the 
lines  of  communication  is  about  5  per  cent. ;  all  these 
deaths  are  from  sepsis.  The  mortality  of  cases  reach- 
ing England  is  small. 

All  observers  are  agreed  that  there  is  a  difference 
in  the  mortality  according  to  the  nature  of  the  pro- 
jectile inflicting  the  injury.  If  a  rifle  bullet  causes  the 
wound,  the  condition  resulting  is  either  very  serious 
if  a  large  vessel  is  struck,  or  very  benign  if  the  lung 
tissue  is  traversed  without  serious  vascular  injury. 
Wounds  from  high  explosive  shell,  the  fragment 
causing  the  wound  being  irregular  and  jagged,  the 
pieces  of  clothing  or  of  skin  being  driven  deeply  in, 
are  always  serious  by  reason  of  the  infection  that  was 
so  prone  to  follow.  Rouvihois,  in  102  cases,  found 
the  following: 

In  60  cases  where  the  projectile  was  retained  there 
were  27  deaths;  in  26  of  these  the  wound  was  caused 
by  shell,  in  1  case  by  rifle  bullet.  In  42  cases  of  per- 
forating wounds  there  were  10  deaths;  in  9  of  these 
the  wound  was  caused  by  shell  and  1  by  rifle  bullet. 
These  are  truly  remarkable  comments  upon  the 
influence  of  the  projectile  in  determining  the  mor- 
tality. 


120  AMERICAN  ADDRESSES 

Death  occurs  chiefly  from  two  causes :  from  haemor- 
rhage and  from  sepsis.  Haemorrhage  is  fatal  early — 
generally  within  the  first  twenty-four  or  forty-eight 
hours.  Sepsis  proves  fatal  at  a  later  stage — generally 
from  the  seventh  day  onward.  The  most  fatal  cases 
are  those  where  there  is  a  gaping  wound  of  the  chest, 
so  that  the  lung  is  freely  exposed.  The  mortality 
in  cases  where  the  chest-wall  is  closed  behind  the 
projectile  is  rather  less  than  one-half  of  that  which 
results  when  there  is  an  open  wound.  Captain  H. 
Henry,  in  100  postmortem  examinations  made  upon 
patients  with  chest  wounds  who  reached  a  base  hos- 
pital in  France,  found  that  the  great  majority  of 
deaths  were  due  to  septic  infection.  Only  four  pa- 
tients died  from  haemorrhage,  and  in  three  of  these 
the  haemorrhage  was  secondary  in  character  and  was 
induced  by  sepsis. 

PATHOLOGICAL  ANATOMY 

The  injuries  inflicted  by  a  projectile  entering  the 
chest  may  be  considered  in  relation  to  their  effects 
upon: 

(a)  The  chest-wall. 

(6)  The  injured  lung. 

(c)   The  opposite  lung. 

The  Chest-wall. — The  damage  done  to  the  chest- 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  121 

wall  may  be  of  the  most  diverse  forms.  There  may- 
be a  clean  penetration  of  the  thorax  from  front  to 
back,  the  projectile,  in  this  case  a  rifle  bullet,  cleav- 
ing a  way  through  all  the  tissues  it  meets  here,  pre- 
cisely as  it  does  when  the  thigh  or  the  soft  parts  any- 
where are  pierced.  In  many  of  these  cases,  however, 
and  in  a  still  larger  number  when  there  is  a  shell- 
wound,  there  is  a  fracture  of  one  or  more  of  the  ribs 
or  of  the  scapula.  Fragments  of  bone,  tiny  spicules, 
or  larger  pieces  are  carried  into  the  chest,  and  at  a 
later  operation  may  be  recognised  and  removed 
either  from  the  lung  itself  or  from  the  pleural  cavity, 
especially  in  the  cul-de-sac  above  the  diaphragm. 
The  same  results  follow  this  scattering  of  the  bone 
into  the  lung  as  occur  when  there  is  a  compound 
fracture  of  the  long  bones  in  the  limbs.  Each  bony 
sequestrum  becomes  itself  a  projectile  driven  with 
force  into  the  tissues,  and  carrying  with  it  a  capacity 
for  infection,  and  inflicting  a  grave  injury  upon  all 
the  parts  through  which  it  tears  its  way.  The  condi- 
tions so  produced  are  serious  and  long  continued. 

In  severer  cases  a  part  of  the  chest-wall  may  be 
destroyed,  being  driven  inward  by  a  massive  piece 
of  shell  casing,  or  being  swept  away  by  a  glancing 
blow.  Few  cases  reach  a  base  hospital  in  France, 
and  still  fewer,  of  course,  in  England,  when  any  large 


122  AMERICAN  ADDRESSES 

part  of  the  parietes  has  been  lost.  Such  cases  die  in 
advance  stations  up  the  line  from  shock  or  from 
haemorrhage.  The  few  that  I  have  seen  at  base  hos- 
pitals were  all  heavily  infected  and  suffered  much 
distress.  Their  condition  is  a  powerful  argument  in 
favour  of  the  early  closure  of  all  parietal  wounds, 
wherever  possible. 

The  Injured  Lung. — The  effects  produced  in  the 
lung  are  strictly  comparable  to  those  produced  in 
other  parts  of  the  body  by  the  various  forms  of  pro- 
jectile. The  points  of  entrance  and  of  exit  in  the 
case  of  perforating  wounds  bear  all  the  appearances 
of  those  seen  in  the  soft  tissues  of  the  thigh.  The 
entrance  wound  is  small,  even  punctate;  the  orifice 
of  exit  is  large,  more  irregular,  and  bears  signs  of 
greater  injury  and  of  a  tendency  to  protrusion  of 
wounded  parts.  Along  the  track  of  the  missile  there 
are  the  same  evidences  of  diffused  injury.  The  parts 
around  are  bruised  and  lacerated;  there  is  a  haemor- 
rhagic  pulmonary  infiltration  of  varying  but  often 
wide  extent.  The  part  of  the  lung  giving  on  to  the 
track  is  contused  or  dead,  and  such  tissue  offers  here 
as  elsewhere  the  most  favourable  opportunities  for 
bacterial  invasion  and  growth.  Postmortem  ex- 
aminations of  wounded  lungs  generally  show  that  the 
track  of  the  projectile,  whatever  it  may  have  been, 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  123 

is  rectilinear.  There  are  no  fissures  or  rifts  radiating 
from  the  main  track,  nor  any  hidden  pockets  shut 
off  from  the  central  channel.  Several  tracks  may  be 
found  in  close  approximation  when  many  fragments 
of  metal  have  entered.  The  bronchi  of  large  or 
medium  size  seem  to  escape  injury  in  the  majority 
of  cases.  In  the  path  of  the  projectile  blood  is  ex- 
travasated  in  the  earliest  hours;  in  later  stages  pus 
may  be  found. 

The  injury  to  the  damaged  lung  is  not,  however, 
confined  to  the  path  of  the  bullet  and  the  parts  im- 
mediately adjacent.  The  distant  parts  of  the  lung 
or  the  pleura  bear  traces  of  lesions,  due  to  the  force 
with  which  the  parts  are  struck  or  to  the  sudden 
constriction  of  the  chest,  followed  by  its  instant 
expansion,  upon  the  impact  of  a  volume  of  com- 
pressed air  caused  by  the  explosion  of  a  shell.  There 
may  be  haemorrhages  by  "cont recoup"  in  the  upper 
lobe  if  the  lower  is  wounded,  or  in  the  lower  if  the 
upper  is  injured,  or  in  both  if  the  projectile  has 
passed  near  the  base  of  the  lung.  These,  as  Duval 
has  shown,  may  be  recognised  at  once  by  the  opa- 
city seen  on  the  radiograph;  and  I  have  found 
in  later  operations  many  recent  adhesions  of  the 
pleura  over  parts  that  could  by  no  possibility  have 
met  with  a  direct  assault  and  evidences  of  intrapul- 


124  AMERICAN  ADDRESSES 

monary  hsemorrhages.  These  conditions  are  of  the 
same  order  as  those  described  in  an  early  fatal  case 
by  Latarket.  He  has  found  a  massive  congestion  of 
the  whole  lung,  a  sort  of  diffuse  hsemorrhagic  infiltra- 
tion involving  the  entire  organ,  in  a  case  in  which  a 
bullet  wound  was  inflicted  at  close  range. 

Such  meagre  postmortem  experience  as  exists 
confirms  the  impression  that  is  derived  from  the 
clinical  examination  of  operated  cases,  that  wounds 
of  the  lung  heal  rapidly  and  kindly. 

The  Opposite  Lung. — It  is  a  new  fact,  learned 
during  this  war,  that  the  opposite  lung  suffers  damage 
also.  Such  lesions  are  frequent,  in  the  severer  cases 
probably  constant.  They  consist  in  small  or  large 
hsemorrhages  beneath  the  pleura  or  in  the  substance 
of  the  lung.  These  may  be  followed  by  filamentous 
or  by  firm  adhesions  between  the  visceral  and 
parietal  pleura  and  by  patches  of  solidity  in  the 
lung  itself.  In  a  late  stage  the  lung  may  present 
all  the  evidences  of  a  bronchopneumonia  at  one 
point  or  in  many.  The  increased  activity  imposed 
upon  the  lung  by  the  restricted  function  of  that  which 
has  been  wounded  no  doubt  renders  it  an  easy  prey 
to  any  malady.  The  presence  of  an  infected  expec- 
toration in  the  trachea  may  lead  to  the  inhalation  of 
purulent  or  septic  material  into  the  uninjured  lung. 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  125 

These  conditions  often  improve  very  rapidly  when 
the  injured  side  is  treated  by  aspiration  of  a  large 
hsemothorax,  or  free  drainage  of  an  empyema. 

Haemorrhage. — When  a  missile  enters  or  traverses 
the  chest,  any  of  the  vessels  contained  therein  may  be 
lacerated.  If  the  larger  vessels  in  the  mediastinal 
cavities  or  in  the  root  of  the  lung  are  divided,  the 
loss  of  blood  is  so  copious  and  rapid  that  death  re- 
sults at  once  and  the  patient  does  not  reach  even  an 
advanced  aid  post. 

In  the  cases  not  immediately  fatal  the  blood  comes, 
in  the  very  great  majority  of  cases,  from  the  lung 
tissue.  Henry  and  Elliott,  as  a  result  of  careful  in- 
vestigation of  the  thoracic  walls  and  the  lung  in  78 
postmortem  examinations  made  on  the  subject  of 
hsemothorax,  came  to  the  conclusion  that  the  bleed- 
ing had  been  of  pulmonary  origin  in  the  great  ma- 
jority of  cases. 

Apart  from  the  cases  dying  instantly  from  haemor- 
rhage, the  deaths  in  the  first  forty-eight  hours  are  all 
due  to  loss  of  blood  from  lung  tissue.  Both  in  the 
French  and  the  English  armies  precocious  operative 
measures  are  being  adopted  in  such  cases  with  a  de- 
gree of  success  that  encourages  a  wide  adoption  of 
this  practice.  If  death  does  not  occur  speedily  from 
haemorrhage,  a  recurrence  of  bleeding  is  not  often 


126  AMERICAN  ADDRESSES 

seen.  Patients  rarely  die  from  haemoptysis,  and 
secondary  haemoptysis  is  extremely  infrequent.  The 
occurrence  of  haemorrhage  through  the  wounds  of 
entry  or  of  exit  is  probably  responsible  for  the  errone- 
ous belief  that  it  is  from  the  chest-wall,  from  the 
intercostal  vessels,  that  the  blood  is  lost. 

Dolbey  records  one  very  remarkable  case  of  gross 
haemorrhage  resulting  from  a  wound  of  the  axillary 
vein.  The  chest  filled  with  blood  from  the  torn  ves- 
sel, but  after  two  large  aspirations,  the  wound  in  the 
vein  healed.  There  was  also  an  aneurysm  of  the 
axillary  artery  treated  by  ligation  of  the  subclavian 
artery  successfully. 

Hgemothorax. — When  blood  escapes  into  the  pleural 
cavity,  what  happens  to  it.^  According  to  Elliott 
and  Henry,  "it  appears  probable  that  clotting  always 
takes  place — and  very  early — through  the  action  on 
the  blood  of  the  ferment  liberated  at  the  surface  of 
the  wounded  tissues;  the  clot  may  be  (a)  complete 
and  massive,  forming  a  soft  and  persistent  clot;  (b) 
massive,  but  with  an  early  and  fairly  extensive  sepa- 
ration of  the  yellow  serum  from  the  clot;  (c)  interfered 
with  by  the  churning  movements  of  respiration'* 
(and  of  the  heart. ^),  "so  that  the  fibrin  is  whipped  out 
in  layers  which  cover  the  pleural  surfaces,  while  the 
serum  retains  most  of  the  red  corpuscles  in  suspen- 
sion." 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  127 

The  amount  of  blood  extravasated  into  the  pleura 
varies  very  much — from  a  few  ounces  up  to  four  or 
even  five  pints.  The  escape  of  blood  is  hindered  and 
at  last  arrested  by  collapse  of  the  lung  and  by  the 
pressure  exerted  by  the  blood  which  has  already 
flowed  into  the  pleural  cavity.  The  response  of  the 
pleura  to  the  contact  of  blood  is  expressed  in  an  in- 
flammatory reaction  which  also  helps  in  some  degree 
to  seal  the  leaking  orifice,  though  it  also  increases 
the  mass  of  fluid  lying  in  the  chest.  In  fact,  the  ad- 
mixture of  fluid  effused  from  the  pleura  accounts  for 
the  fact  that  in  many  cases  the  condition  of  the  com- 
bined fluids  does  not  conform  with  that  seen  when 
only  blood  is  extravasated. 

Hsemothorax  in  itself,  though  disabling  enough 
and  productive  of  such  general  effects  as  the  loss  of 
a  large  quantity  of  blood  necessarily  entails,  is  not 
dangerous  to  life,  apart  from  infection.  The  bacteria 
chiefly  responsible  for  this  hazardous  complication 
are,  according  to  Duval : 

1.  Derived  from  the  respiratory  tract: 
Pneumococcus. 
Staphylococcus. 
B.  tetragenus. 
B.  of  Pfeiffer. 

2.  Derived  from  the  wound: 
Streptococcus. 
B.  coll. 


A.  Aerobic 


128  AMERICAN  ADDRESSES 

Bacillus  of  Welch. 


B.  Anaerobic  -,  „ 

B.  sporogenes. 

The  most  common  association  is  of  the  Bacillus 
coli  with  the  gas  gangrene  bacillus. 

The  frequency  of  infection  may  be  gauged  from  the 
figures  given  by  Captain  Henry.  Out  of  500  speci- 
mens of  fluid  obtained  by  tapping,  in  the  ordinary 
routine  of  work  195  were  found  to  be  infected,  and 
of  these,  87  were  infected  by  anaerobic  organisms. 
These  may  be  distributed  from  the  first  throughout 
the  bulk  of  fluid,  or  they  may  be  retained  in  the 
fibrinous  mass  at  the  bottom  of  the  pleura  for  a  longer 
or  shorter  period,  being  disseminated  at  last  through 
the  supernatant  fluids  as  a  result  of  the  respiratory 
movements.  This  accounts  for  the  fact  that  the  first 
puncture  made  for  diagnostic  purposes  was  found  by 
Elliott  and  Henry  in  50  per  cent,  of  pure  infections 
by  anaerobic  bacilli  to  be  negative.  The  syringe 
introduced  into  the  upper  fluid  part  of  the  hsemo- 
thorax  may  discover  no  organisms,  whereas  one  made 
lower  down,  into  the  more  solid  fibrinous  clot,  may 
give  positive  results.  The  infection  may  be  derived 
from  the  projectile  or  clothing  carried  into  the  wound 
at  the  moment  of  the  infliction,  or  may  be  derived 
at  a  later  stage  from  the  focus  in  the  lung  or  from  the 
suppurating    external    wound.      P.    Duval,    in   the 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  129 

Somme  battles,  had  charge  of  193  cases  of  gunshot 
wound  of  the  chest.  Of  these,  49  were  due  to  bullet 
wounds,  none  of  them  had  an  infected  hsemothorax, 
there  were  33  perforating  wounds  from  shell  frag- 
ments, and  among  these  were  6  of  infected  hsemo- 
thorax — 18  per  cent.  There  were  111  penetrating 
wounds;  among  these  were  28  of  infected  haemothorax 
(24  per  cent.). 

TREATMENT 

Upon  one  point  all  those  who  have  been  respon- 
sible for  the  treatment  of  a  patient  with  a  chest 
wound  are  in  complete  and  confident  agreement.  The 
earliest  and  the  most  perfect  immobilisation  is  neces- 
sary. Movements  of  all  kinds  are  to  be  avoided,  and 
therefore  retention  of  the  wounded  man  at  the  Cas- 
ualty Clearing  Station  for  many  days  is  a  paramount 
necessity.  The  fact  that  in  the  first  two  days  the 
deaths  are  due  chiefly  to  haemorrhage  and  in  later 
stages  to  sepsis  must  direct  the  timely  and  appro- 
priate treatment.  Early  operations  for  the  purpose 
of  arresting  haemorrhage  from  the  lung  tissue  have 
been  tried  out  in  certain  hospitals  in  either  the  French 
or  the  British  zones;  but  so  far  as  the  results  of  the 
work  have  gone,  they  appear  to  justify  a  continuance 
of,  and  indeed  a  general  adoption  of,  the  principle 


130  AMERICAN  ADDRESSES 

of  early  direct  treatment  of  the  wound.  It  is,  I 
think,  largely  owing  to  the  advocacy  and  to  the  suc- 
cessful practice  of  P.  Duval  that  an  earlier  surgical 
attack  is  now  considered  necessary  upon  the  graver 
kind  of  lung  case. 

Immediate  intervention,  according  to  Duval,  should 
comprise : 

I.  Closure  of  the  chest- wall  in  cases  of  "open 
thorax." 

II.  Thoracotomy  with  suture  or  plugging  of  the 
wound  in  the  lung  in  case  of  grave  haemorrhage  or 
of  threatening  asphyxia. 

III.  Treatment  of  progressive  surgical  emphysema. 

I.  Closure  of  the  chest-wall,  an  operation  prac- 
tised by  Larrey  in  the  Napoleonic  wars,  has  as  its 
aim  the  suture  of  the  muscles  and  skin  in  order  to 
avoid  traumatopnoea,  pneumothorax,  and  a  continu- 
ing infection  of  the  pleura  from  the  suppurating  ex- 
ternal wound.  The  principles  are  those  guiding  the 
surgeon  in  all  similar  wounds  elsewhere;  the  results 
in  the  saving  of  life  and  suffering  are  incalculable. 
The  gravity  of  the  cases  of  '*open  thorax"  can  hardly 
be  exaggerated.  When  a  part  of  the  chest-wall  has 
been  torn  away  the  lung,  often  bruised  or  lacerated, 
is  exposed,  it  retracts  toward  the  hilum,  and  leaves 
gaping  and  bare  a  huge  cavity  wherein  putrefaction 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  131 

may  occur  and  a  large  surface  from  which  absorption 
can  take  place.  It  is  most  urgently  necessary  to  close 
such  ghastly  wounds  if  it  is  physically  possible. 
Gregorie  has  accomplished  this  in  17  cases,  of  whom 
16  recovered. 

II.  Thoracotomy  is  formally  indicated  in  all  cases 
of  wound  of  the  lung  causing  haemorrhage.  Suture  of 
the  lung  tissue  affords  perfect  hsemostasis.  When  any 
foreign  body,  projectile,  or  sequestrum  is  felt,  the 
lung  is  incised  over  it  if  necessary,  and  after  extrac- 
tion of  the  foreign  body,  the  wound  is  stitched  up 
accurately.  Any  blood  lying  in  the  pleura  is  care- 
fully evacuated,  perfect  cleansing  of  the  cavity  is 
insured,  and  the  wound  is  closed,  it  may  be  after  a 
gentle  wiping  of  the  parts  with  ether.  There  is  no 
need  for  drainage. 

III.  In  the  treatment  of  progressive  emphysema 
closure  of  the  wound  in  the  lung  will  shut  off  the  chan- 
nel through  which  the  air  escapes  into  the  tissues. 
Multiple  skin  incisions  will  relieve  the  tissues  already 
distended  and  crepitant.  In  cases  of  simple  penetrat- 
ing wounds  a  cleansing  and  excision  of  the  wounds, 
followed  by  a  complete  approximation  of  the  edges, 
is  all  that  is  necessary.  In  many  cases  even  excision 
is  not  required;  the  points  of  entrance  and  of  exit  may 
be  cleaned  and  covered  with  a  sterile  dressing. 


132  AMERICAN  ADDRESSES 

When  a  hsemothorax  is  present,  no  interference,  as 
a  rule,  is  needed  for  some  days.  There  may  be  ex- 
ceptions to  this  rule  when  the  rapid  or  the  large  ac- 
cumulation of  fluid  is  causing  urgent  dyspnoea  which 
threatens  the  life  of  the  patient.  The  dangers  of 
early  aspiration  of  the  fluid  are,  of  course,  related 
to  the  reopening  of  the  pulmonary  wound,  which, 
lightly  sealed,  may  bleed  afresh  as  the  lung  expands. 
At  the  end  of  a  week  or  thereabouts  aspiration  of  the 
blood  has  probably  a  most  beneficial  effect  upon  the 
lung,  allowing  it  to  expand  much  more  rapidly  than 
would  otherwise  be  possible,  and  preventing  the  for- 
mation of  those  dense  crippling  adhesions  which  may 
embarrass  the  free  action  of  the  lung  for  a  long  time 
to  come,  or  even  permanently.  Operations  on  cases 
in  England,  in  which  the  blood  has  been  left  in  the 
pleural  cavity,  reveal  an  extreme  density  and  a  wide 
extent  of  adhesions.  X-ray  examination  also  demon- 
strates the  firm  union  that  is  formed  between  the 
two  layers  of  the  pleura.  Withdrawal  of  the  fluid 
is  therefore  most  desirable;  its  replacement  during 
aspiration  by  oxygen  allows  more  fluid  to  be  taken, 
and  causes  the  minimum  of  distress  to  the  patient. 

In  cases  of  large  hsemothorax  which  presumably 
have  remained  sterile,  and  in  which  no  active  treat- 
ment has  been  adopted,  there  is  a  protracted  period 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  133 

of  incapacity  of  the  lung.  I  have  seen  such  cases 
many  months  after  the  injury  in  which  the  percus- 
sion-note was  still  dull,  the  breath-sound  was  absent 
or  diminished,  the  chest  flat,  and  the  respiratory 
movements  very  restricted.  On  examination  by 
x-ray  a  greatly  thickened  pleura  was  diagnosed  and 
immobility  of  the  diaphragm  observed  on  the  affected 
side.  If  aspiration  is  performed,  the  appearance  of 
the  fluid  gives  valuable  information  as  to  its  condi- 
tion in  respect  of  bacterial  infection.  If  the  fluid 
closely  resembles  new  port  wine  in  colour,  it  is  free 
from  infection;  if  it  is  clear  and  almost  colourless,  the 
amount  of  blood  contained  is  small;  most  of  the  fluid 
is  then  the  result  of  a  pleuritic  effusion.  A  turbid 
fluid  like  weak  cocoa,  or  an  effusion  with  any  suspi- 
cion of  offensiveness,  indicates  that  infection  is  pres- 
ent and  that  the  condition  is  one  to  be  treated  as  an 
empyema. 

When  a  hsemothorax  has  become  infected,  then 
thoracotomy  is  necessary.  In  the  early  period  of  the 
war  the  operation  was  practised  on  the  lines  of  the 
civil  operation  for  empyema.  A  short  piece  of  rib 
was  excised,  the  putrid  and  most  offensive  fluid  evac- 
uated, and  a  large  drainage-tube  introduced.  Such 
cases  remain  sometimes  for  weeks,  even  for  months, 
in  the  open  wounds.    Tuffier  has  modified  profoundly 


134  AMERICAN  ADDRESSES 

for  the  better  the  treatment  of  these  tedious  and  most 
trying  cases  by  adapting  to  their  needs  the  Carrel- 
Dakin  technique.  The  operation,  in  so  far  as  resection 
of  the  rib  and  evacuation  of  the  fluid  are  concerned, 
is  precisely  similar  to  the  procedure  in  cases  of  em- 
pyema, but  instead  of  one  large  tube,  several  small 
tubes  threaded  with  wire  are  placed  over  the  cavity 
at  well-judged  intervals.  Their  position  and  proper 
distribution  may  be  confirmed  if  an  x-ray  is  taken. 
A  little  loose  gauze  is  packed  into  the  wound,  and  a 
safetjT^-tube  for  drainage  of  excess  fluid  in  one  angle 
of  the  incision.  Dakin's  fluid  is  instilled  in  the  usual 
manner.  At  the  end  of  ten  days  all  discharge  (there 
is  rarely  more  than  an  extremely  small  quantity  after 
the  first  two  days)  has  ceased,  and  the  tubes  are 
therefore  removed  and  the  wound  closed. 

There  is  no  doubt  that  many  cases  of  suppurating 
haemothorax  would  do  better  if  operated  upon  quite 
eai'ly  by  a  wide  opening  of  the  chest  and  a  complete 
clearing  away  of  all  masses  of  clot  and  pleural  lymph, 
often  so  tenaciously  adherent,  and  by  removal  of  any 
projectiles.  Patients  so  operated  upon  or  operated 
by  the  older  methods  linger  on  in  unsatisfactory  con- 
ditions for  such  long  periods  at  home  that  every  fair 
opportunity  that  offers  for  curtailing  the  tedious  and 
not  wholly  safe  period  of  their  convalescence  must  be 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  135 

embraced.  The  Carrel-Dakin  technique  will  here 
find  one  of  its  most  valuable  indications.  This  is 
only  to  bring  the  treatment  of  wounds  of  the  lung 
into  line  with  that  of  wounds  elsewhere.  The  sur- 
geon no  longer  allows  infection  to  be  well  established 
in  the  wound;  his  aim  is  to  attack  by  approved 
methods  [the  free  opening  of  the  wound,  the  excision 
of  all  dead  or  contaminated  tissue,  the  removal  of 
all  fragments  of  clothing,  of  all  projectiles,  and  of 
all  foreign  bodies]  and  then  to  secure  the  earliest 
possible  closure  of  the  wound  which  remains.  No 
less  an  ideal  and  no  less  scrupulous  a  practice  should 
guide  him  also  in  the  treatment  of  wounds  of  the 
lung  and  pleura.  The  time  has  gone  by  when  he  can 
justly  allow  an  infection  to  become  deeply  ingrained 
before  adopting  those  tardy,  incomplete,  and  often 
ineffective  methods  with  which  he  has  been  too  long 
content. 

What  is  the  history  of  patients  in  whose  lungs  pro- 
jectiles are  retained.^  Our  knowledge  does  not  allow 
us  as  yet  to  answer  this  question  fully.  But  a  cer- 
tain experience  is  not  likely  to  be  changed  by  a  larger 
survey  of  cases.  We  may  say  with  confidence  that 
a  rifle  bullet  or  a  small  piece  of  shell  casing  may  be 
retained  for  months  or  years  without  causing  distress 
and  without  affecting  appreciably  the  normal  func- 


136  AMERICAN  ADDRESSES 

tions  of  the  lung  in  which  it  lies  buried.  But  with 
large  or  irregular  pieces  of  shell  the  case  is  different. 
I  have  seen  many  patients  suffering  for  twelve  or 
eighteen  months  from  cough,  with  haemoptysis  at  in- 
tervals. In  two  cases  the  loss  of  blood  was  serious. 
And  in  many  patients  there  is  an  increasing  complaint 
of  pain,  dyspnea  on  exertion,  and  of  expectoration  of 
mucus. 

For  these  reasons  I  have  recently  given  special  at- 
tention to  these  patients  and  have  submitted  a  num- 
ber of  them  to  operation.  The  results  so  far  entitle 
me  to  say  that  it  is  probably  a  safer,  and  it  is  certainly 
a  speedier,  procedure  to  submit  all  patients  in  whose 
lungs  a  large  projectile  is  retained  to  operation  rather 
than  to  leave  them  untreated.  In  almost  every  case 
operated  upon  the  projectile  has  been  dropped  at 
once  into  a  culture-medium:  with  one  exception  all 
missiles  were  infected;  the  organism  most  commonly 
found  was  the  staphylococcus. 

The  following  are  the  details  of  the  procedure 
adopted  for  the  extraction  of  bullets  from  the  lung. 
Its  principles  have  been  firmly  established  by  the 
work  of  Pierre  Duval.  The  operation  is  performed 
under  anaesthesia  induced  by  ether  and  oxygen.  A 
preliminary  injection  of  morphin  and  atropin  is 
given  about  half  an  hour  before  the  operation. 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  137 

The  patient  lies  flat  on  his  back,  with  the  arms  at 
the  sides.  A  curved  incision,  about  5  or  6  inches  in 
length,  is  made  exactly  along  the  line  of  the  fourth 
rib.  The  fibres  of  the  pectoralis  major  are  split,  and 
the  pectoralis  minor  is  separated  from  the  rib.  There 
are  many  points  of  haemorrhage  requiring  a  clip  or  a 
ligature.  All  must  be  carefully  secured  so  that  there 
is  a  perfectly  dry  field.  The  rib  and  the  costal  carti- 
lage are  exposed  for  a  distance  of  not  less  than  5 
inches.  An  incision  is  made  through  the  periosteum, 
midway  between  the  upper  and  lower  borders,  and 
this  membrane  is  stripped  from  the  rib  on  both  sur- 
faces. A  curved  raspatory  of  Doyen's  pattern  is 
very  useful  for  the  purpose.  In  my  earlier  operations 
I  cut  through  the  costal  cartilage  and  then  divided 
the  rib  with  forceps  so  that  a  length  of  4  to  5  inches 
of  the  rib  could  be  removed.  In  later  operations  I 
have  freed  the  inner  end  of  the  rib  after  division  of 
the  cartilage,  have  passed  a  strip  of  gauze  beneath 
it,  and  pulled  it  upward  and  outward,  causing  a 
fracture,  often  of  the  "greenstick"  type,  a  little  be- 
hind the  middle  of  the  rib.  In  this  way  the  rib  may 
be  saved  and  replaced  at  the  end  of  the  operation. 
This,  however,  is  not  a  point  of  great  importance, 
for  when  the  periosteum  is  left,  a  new  rib  is  formed 
very  rapidly,  and  the  chest-wall  soon  becomes  as 


138  AMERICAN  ADDRESSES 

firm  as  ever.  Care  is  taken  in  excising  the  rib  and  in 
lifting  it  away  not  to  wound  the  pleura,  which  must 
be  separated  widely  from  the  ribs  above  and  below, 
to  the  inner  and  the  outer  side  of  the  wound.  Unless 
this  is  done,  accurate  closure  of  the  pleura  later  on, 
always  difficult,  will  be  impossible.  A  retractor  is 
now  placed  in  the  wound  to  widen  the  interval  be- 
tween the  ribs  above  and  below.  Any  abdominal 
retractor  will  do,  but  the  best  instrument  I  have  used 
is  that  invented  for  this  special  purpose  by  Tuffier. 
As  wide  a  gap  as  possible  is  made,  so  that  the  whole 
hand  can  easily  be  passed  into  the  chest. 

The  pleura  is  now  incised  along  the  line  of  the  rib, 
and  air  enters  freely  and  at  once  into  the  pleural 
cavity.  As  a  rule,  this  causes  no  disturbance  and  does 
not  alter  the  rate  of  the  respirations  or  of  the  pulse. 

The  hand  is  now  passed  into  the  chest  cavity. 
Adhesions  of  the  lung  to  the  parietal  pleura  may  be 
encountered.  These  are  sometimes  very  slender  and 
easily  broken  through.  At  times  they  are  tough  and 
strong  and  are  with  great  difficulty  severed.  If  they 
are  numerous  or  thick  and  tough,  bleeding  may  occur 
quite  freely  for  a  minute  or  two.  With  gentle  pres- 
sure from  a  hot,  moist  swab  the  oozing  is  soon 
checked.  In  a  case  where  a  projectile  was  in  the  base 
of  the  right  lung  posteriorly,  the  whole  of  the  lower 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  139 

lobe  and  a  great  part  of  the  upper  lobe  were  most 
intimately  adherent  to  the  parietal  pleura  and 
patches  of  the  lung  felt  solid.  The  adhesions,  how- 
ever, separated  in  just  the  same  way  as  adhesions 
within  the  abdomen  separate,  by  gentle  pressure  and 
stripping.  Thoracic  adhesions  bleed,  I  think,  far 
more  freely  than  those  encountered  in  the  abdomen. 
When  all  are  loosened,  the  collapsed  lung  lies  free 
within  the  pleural  cavity.  It  may  now  be  seized  with 
the  fingers  or  with  a  special  light  form  of  clip  and 
drawn  up  to  the  anterior  wound,  and,  little  by  little, 
be  coaxed  out  of  the  wound.  It  is  surrounded,  as  it 
appears,  by  warm  cloths  soaked  in  normal  saline 
solution.  When  a  lobe  of  the  lung  is  freely  delivered, 
it  is  palpated  from  top  to  bottom.  Any  projectile 
embedded  in  it  is  felt,  as  a  rule,  at  once.  Even 
little  sequestra  blown  in  from  a  rib  may  be  recog- 
nised without  any  difficulty.  These  foreign  bodies 
are  as  easily  recognised  as  the  particles  of  gritty 
sand  in  a  new  sponge.  When  the  projectile  is  felt, 
the  part  of  the  lung  containing  it  is  made  prominent, 
the  lung  tissue  lying  over  it  is  incised,  the  metal  re- 
moved, and  the  wound  sutured.  Deep  stitches  of 
catgut  are  passed  through  the  lung  substance,  and 
with  gentle  tension  act  as  a  haemostatic.  If  neces- 
sary, very  fine  catgut  sutures  may  be  used  to  secure 


140  AMERICAN  ADDRESSES 

the  accurate  apposition  of  the  pleural  edges.  If 
there  is  any  bleeding  from  the  collapsed  lung,  it  is 
slight  and  easily  controlled,  but  precision  in  suture  is 
most  desirable,  for  expansion  of  the  lung  will  rapidly 
be  secured  when  the  operation  is  completed.  If  there 
are  two  or  more  particles  of  shrapnel  or  shell  casing 
in  the  lung,  they  are  all  dealt  with  in  the  same  way. 
I  have  once  incised  the  hilum  of  the  lung  and  stitched 
it  up  without  difl&culty.  When  the  sutures  are  com- 
pleted, the  lung  is  replaced,  the  cavity  of  the  pleura 
most  carefully  dried  and  emptied,  and  a  gauze  swab 
wet  with  ether  wiped  over  the  visceral  pleura  and  over 
any  adhesions  which  may  have  been  separated.  The 
retractor  is  removed  and  the  parietal  pleura  now 
stitched  up.  This  is  quite  the  most  difficult  part  of 
the  operation;  indeed,  I  have  not  been  able  to  close 
the  pleura  accurately  unless  this  membrane  has  been 
stripped  up  freely  from  the  chest-wall  before  being 
incised.  The  rib,  if  it  has  been  turned  back,  is  re- 
placed, and  fixed  in  position  by  a  suture  through  the 
costal  cartilage.  The  muscles  are  carefully  sutured, 
and  the  wound  edges  accurately  approximated  with- 
out drainage.  The  closure  of  the  wound  should  be 
so  carefully  done  as  to  seal  the  chest  hermetically. 
When  the  dressing  is  applied,  a  two-way  needle  may 
be  plunged  into  the  chest,  and  the  ether  and  air  ex- 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA  141 

tracted  therefrom.     The  lung  then  rapidly  expands, 
and  faint  breath-sounds  are  heard  at  once. 


CONCLUSIONS 

The  following  general  conclusions  may  be  stated: 

1.  The  approximate  mortality  from  gunshot 
wounds  of  the  chest  at  all  parts  of  the  line  of  com- 
munication is  20  per  cent. 

2.  The  causes  of  death  are  haemorrhage,  as  a  rule, 
within  forty-eight  hours,  and  sepsis  after  the  fourth 
or  fifth  day. 

3.  The  local  conditions  in  wounds  of  the  chest-wall 
and  lung  are  in  all  respects  similar  to  those  met  with 
in  wounds  elsewhere.  The  missiles  are  the  same, 
their  destructive  effects  upon  the  tissues  are  the  same, 
and  the  infecting  organisms  are  the  same. 

4.  The  lung  tissue  is  more  resistant  to  attack  than 
are  many  other  tissues.  The  opening  of  the  pleural 
cavity  and  the  resulting  exposure  of  a  large  serous 
sac  to  infection  and  all  its  consequences  add,  how- 
ever, a  danger  of  the  most  threatening  character. 

5.  The  chief  essential  in  the  treatment  of  all  cases 
of  penetrating  wounds  of  the  chest  is  rest. 

6.  In  clean  perforating  wounds  of  the  chest  rest, 
together  with  the  cleansing  and  dressing  of  the  wound 


142  AMERICAN  ADDRESSES 

of  entrance  or  exit,  will  lead  to  the  recovery  of  the 
great  majority  of  cases. 

7.  In  cases  of  "open  thorax"  the  earliest  and  most 
complete  effort  possible  must  be  made  to  secure 
closure  of  the  wound  after  an  appropriate  toilet. 

8.  In  those  rare  cases  of  grave  haemorrhage,  when 
haemoptysis  is  present  or  when  the  blood  escapes  by 
the  wound,  a  direct  access  to  the  source  of  the  bleed- 
ing must  be  obtained,  when  all  contingent  circum- 
stances permit,  and  the  wound  in  the  lung  must  be 
treated  by  suture,  preferably,  or  by  plugging  of  the 
cavity  from  which  the  blood  escapes. 

9.  In  cases  of  hsemothorax,  when  the  blood  effused 
is  small  in  quantity  and  remains  sterile,  no  active 
measures  are  necessary  unless  absorption  is  long  de- 
layed. Aspiration,  repeated,  if  necessary,  may  then 
be  performed. 

10.  In  cases  of  hsemothorax,  when  the  blood  effused 
is  large  in  amount  and  remains  sterile,  aspiration 
after  the  seventh  or  eighth  day,  or  earlier  in  cases  of 
urgent  dyspnoea,  certainly  hastens  convalescence,  per- 
mits a  more  rapid  expansion  of  the  lung,  and  prevents 
the  formation  of  firm  adhesions  which  may  perma- 
nently cripple  the  free  movements  of  the  lung. 

11.  In  cases  of  hsemothorax,  whether  the  amount 
of  blood  is  small  or  large,  when  infection  takes  place. 


GUNSHOT  WOUNDS  OF  LUNGS  AND  PLEURA    143 

open  operation  is  necessary.  Early  operation,  espe- 
cially of  the  Carrel-Dakin  technique,  if  adopted,  saves 
many  weeks  of  tedious  convalescence  and  permits  of 
a  more  perfect  functional  recovery. 

12.  Small  foreign  bodies  or  rifle  bullets  embedded 
in  the  lung  often  cause  no  symptoms :  they  become 
encapsulated  and  may  safely  be  left. 

13.  Larger  foreign  bodies  retained  in  the  lung  may 
cause  distressing  or  disabling  symptoms  for  long 
periods.  In  such  cases  removal  after  resection  or 
elevation  of  the  fourth  rib  through  an  anterior  inci- 
sion will  allow  of  the  safe  removal  of  the  projectile 
from  any  part  of  the  lung.  Pieces  of  metal  so  re- 
moved are  generally  infected. 


SAUNDERS*   BOOKS 


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Stelwa^on  on  the  Skin 

A  Treatise  on  Diseases  of  the  Skin.  By  Henry  \V. 
Stelwagon,  M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the 
Jefferson  Medical  College,  Philadelphia,  Octavo  of  1 309  pages, 
with  356  text-cuts  and  ^^  plates.     Cloth,  ;^6.5o  net. 

Eighth  Edition  published  November,  1916 

The  demand  for  eight  editions  of  this  work  in  such  a  short  period  indicates 
the  practical  character  of  the  book.  In  this  edition  the  articles  on  Frambesia, 
Oriental  Sore,  and  other  tropical  diseases  have  been  entirely  rewritten.  The  new 
subjects  include  Occupational  Dermatoses,  Paraffinoma,  Purpura  Annularis,  Telan- 
giectodes, Xanthoma  Elasticum,  and  Ulerythema  Ophryogenes.  George  T,  Elliot, 
M.  D.,  Professor  of  Dermatology,  Cornell  University,  says:  "It  is  a  book  that  I 
recommend  to  my  class  at  Cornell,  because  for  conservative  judgment,  for  accurate 
observation,  and  for  a  thorough  appreciation  of  the  essential  position  of  dermatol- 
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about     any    books    in    which     you     are     interested 


SAL'XDERS'    BOOKS   ON 


Schamberg's  Diseases  of   the 
Skin  and  Eruptive  Fevers 

Diseases  of  the   Skin   and    Eruptive   Fevers.     By  Jay 

F.  ScHAMBERG,  M.  D. ,  Professor  of  Dermatology  and  the  In- 
fectious Eruptive  Diseases,  Philadelphia  Polyclinic.  Octavo  of 
585  pages,  illustrated.     Cloth,  $3.25  net. 

THIRD  EDITION— published  September.  1915 

Dr.  Schamberg  takes  up  all  diseases  of  the  skin,  giving  special 
emphasis  to  those  diseases  met  most  frequently  in  general  practice. 
The  work  is  particularly  full  on  aciinotkerapy,  rontgenotherapy,  and 
radium,  these  modern  measures  being  discussed  in  a  separate  chap- 
ter as  well  as  under  the  various  diseases.  The  exanthemata  are 
considered  in  a  special  chapter,  diagnosis  and  treatment  being  given 
unusual  space.  In  addition,  there  are  described  the  usual  and  the 
accidental  eruptions  occurring  in  such  diseases  as  typhoid,  epidemic 
cerebrospinal  meningitis,  influenza,  malaria,  tonsillitis,  etc.  This 
is  an  important  feature.  PAY  the  new  vaccines  and  serums  are  con- 
sidered— their  use  both  in  diagnosis  and  treatment.  The  many 
comparative  tables  of  symptoms  and  the  wealth  of  reliable  pre- 
scriptions make  "  Schamberg  "  a  most  practical  work  for  the  gen- 
eral practitioner  as  well  as  for  the  specialist. 

Johns  Hopkins  Hospital  Bulletin 

"The  descriptions  of  the  eruptions  are  so  clear  and  concise  that  the  appearance  of  a 
dise.Tie  can  readily  be  imagined.  The  arrangement  of  diagnosis  of  many  of  the  diseases  is 
excellent,  the  points  considered  being  placed  opposite  one  another  in  parallel  rows." 

Asher's  Chemistry  ^  Toxicology  for  Nurses 

Chemistry  and  Toxicology  for  Nurses.  By  Philip  Asher, 
Ph.  G.,  M.  D.,  Dean  and  Professor  of  Chemistry,  New  Orleans  Col- 
lege of  Pharmacy.     l2mo  of  190  pages.  Cloth,  ^1.25   net. 

Dr.  Asher's  one  aim  in  writing  this  book  was  to  emphasize  throughout  the  applica- 
tion of  chemical  and  toxicologic  knowledge  in  the  practice  of  nursing.  This  he  has 
succeeded  in  doing.  The  nurse,  both  in  training-school  and  in  graduate  practice, 
will  find  it  extremely  helpful  because  the  subject  is  made  so  clear.         October.  1914 


GENITO- URINA RY  D /SEASES. 


Norris'  Gonorrhea  in  Women 

Gonorrhea  in  Women.  By  Charles  C.  Norris,  M.  D., 
Instructor  in  Gynecology,  University  of  Pennsylvania.  With  an 
Introduction  by  John  G.  Clark,  M.  D.,  Professor  of  Gynecology, 
University  of  Pennsylvania.  Large  octavo  of  520  pages,  illus- 
trated.    Cloth,  $6.50  net. 

A  CLASSIC 

Dr.  Norris  here  presents  a  work  that  is  destined  to  take  high  place  among 
publications  on  this  subject.  He  has  done  his  work  thoroughly.  He  has 
searched  the  important  literature  very  carefully,  over  2300  references  being 
utilized.  This,  coupled  with  Dr.  Norris'  long  experience,  gives  his  work  the 
stamp  of  authority.  The  chapter  on  serum  and  vaccine  therapy  and  organo- 
therapy is  particularly  valuable  because  it  expresses  the  newest  advances. 
Every  phase  of  the  subject  is  considered :  History,  bacteriology,  pathology 
sociology,  prophylaxis,  treatment  (operative  and  xntdxcmal),  gonorrhea  during 
pregnancy,  parturition  and  the  puerperium,  diffuse  gonorrheal  peritonitis,  and 
all  other  phases.  Further,  Dr.  Norris  considers  the  rare  varieties  of  gonorrhea 
occurring  in  men,  women,  and  children.  Published  May,  1913 


Coolidg'e  on  Nose  and  Throat 

Manual  of  Diseases  of  the  Nose  and  Throat.  By  Algerno^t 
CooLiDGE,  M.  D.,  Professor  of  Laryngology,  Harvard  Medical 
School.     Octavo  of  360  pages,  illustrated.     Cloth,  I1.50  net. 

READY   REFERENCE 


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Established  facts  are  emphasized  and  unproved  statements  avoided.  Anat- 
omy and  physiology  of  the  different  regions  are  reviewed. 

Published  September,  191S 


SAUA'DERS'  BOOKS  OX 


Braasch's  Pyelography 

Pyelography  (Pyelo=Ureterography).  By  William  F. 
Braasch,  M.  D.,  Mayo  Clinic,  Rochester,  Minn.  Octavo  of 
323  pages,  with  296  pyelograms.     Cloth,  $5.00  net. 

296  PYELOGRAMS 

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several  thousand  made  at  the  Mayo  Clinic  during  the  past  five  years.  You  get 
the  outlines  of  normal  pelves,  those  of  pathologic  conditions,  and  those  of  con- 
genitally  abnormal  pelves.  In  addition  to  the  pyelograms,  you  get  a  des- 
criptive text,  intrepreting  the  outlines,  pointing  out  their  great  value  in  diagnosis. 
You  get  the  history  of  pyelography  and  the  exact  technic — selection  of 
medium  to  be  injected,  preparation  of  solution,  method  of  injection,  sources 
of  error,  etc.  The  work  is  a  most  complete  one,  beautifully  gotten  up,  and 
contains  much  matter  of  great  diagnostic  value.  Published  March,  1915 


O^den  on  the  Urine  TWrd  Edition 

Clinical  Examination  of  Urine  and  Urinary  Diag- 
nosis. A  Clinical  Guide  for  the  Use  of  Practitioners  and 
Students  of  Medicine  and  Surgery.  By  J.  Bergen  Ogden, 
M.  D.,  Medical  Chemist  to  the  Metropolitan  Life  In- 
surance Company,  New  York.  Octavo,  418  pages,  54  text- 
illustrations,  and  a  number  of  colored  plates.     Cloth,  $3.00 

net.  PubUshed  October,  1909 

"We  consider  this  manual  to  have  been  well  compiled  ;  and  the  author's  own 
experience,  so  clearly  stated,  renders  the  volume  a  useful  one  both  for  study 
and  reference." — 77^4.'  Lancet,  London. 

Vecki's  Sexual  Impotence  FifthEdiuon 

Sexual  Impotence.  By  Victor  G.  Vecki,  M.  D. 
i2mo  volume  of  400  pages.     Cloth,  $2.25  net. 

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and  judicious." — Johns  Hopkins  Hospital  Bul/etin.      Published  December,  1915 


DISEASES   OF   THE   EYE. 


DeSchweinitzV 
Diseases  of  the  Eye 

The  New  (8th)  Edition 

Diseases  of  the  Eye :  A  Handbook  of  Ophthalmic 
Practice.  By  G.  E.  deSchweinitz,  M.  D.,  Professor  of 
Ophthalmology  in  the  University  of  Pennsylvania,  Philadelphia, 
etc.  Handsome  octavo  of  754  pages,  386  text-illustrations, 
and  7  chromo-lithographic  plates.       Cloth,  $6.00  net. 

Published  June,  1916 

WITH    386   TEXT-ILLUSTRATIONS  AND  7  COLORED  PLATES 

Dr.  deSchweinitz"s  book  has  long  been  recognized  as  a  standard  authority 
upon  eye  diseases,  the  reputation  of  its  author  for  accuracy  of  statement 
placing  it  far  in  the  front  of  works  on  this  subject.  For  this  edition  Dr. 
deSchweinitz  has  subjected  his  book  to  a  most  thorough  revision.  Many 
new  subjects  have  been  added,  a  number  in  the  former  edition  have  been 
rewritten,  and  throughout  the  book  reference  has  been  made  to  vaccine  and 
serum  therapy,  to  the  relation  of  tuberculosis  to  ocular  disease,  and  to  the 
value  of  tuberculin  as  a  diagnostic  and  therapeutic  agent. 

The  text  is  fully  illustrated  with  black  and  white  cuts  and  colored  plates, 
and  in  every  way  the  book  maintains  its  reputation  as  an  authority. 

Johns  Hopkins  Hospital  Bulletin 

"  No  single  chapter  can  be  selected  as  the  best.  They  are  all  the  product  of  a  finished 
authorship  and  the  work  of  an  exceptional  ophthalmologist.  The  work  is  certainly  one  of 
the  best  on  ophthalmology  extant,  and  probably  the  best  by  an  American  author." 

deSchweinitz    and    Holloway    on    Pulsating' 

E^XOphthalmOS  published  August,  1908 

Pulsating  Exophthalmos.  An  analysis  of  sixty-nine  cases  not  pre- 
viously analyzed.  By  George  E.  deSchweinitz,  M.  D.,  and  Thomas 
B.  Holloway,  M.  D.     Octavo  of  125  pages.     Cloth,  $2.00  net. 

"The  book  deals  very  thoroughly  with  the  whole  subject,  and  in  it  the  most  com 
plete  account  of  the  disease  will  be  found." — British  Medical  Journal. 

Jackson's  Essentials  of  Eye         Fourth  Revised  Edition 

Essentials  of  Refraction  and  of  Diseases  of  the  Eye.  Bj^ 
Edward  Jackson,  A.  M.,  M.  D.,  Emeritus  Professor  of  Diseases  of  the 
.  Eye,  Philadelphia  Polyclinic.  Post-octavo  of  261  pages,  82  illustra- 
tions.    Cloth,  $1.25  net.     In  Saunders'  Question-Corn pend  Series. 

"  The  entire  ground  is  covered,  and  the  points  that  most  need  careful  elucidation  are 
made  clear  and  easy." — Johns  Hopkins  Hospital  Bulletin.  Published  April,  1906 


SACXDEA'S-    JSOOA'S    O.V 


GET  A*%^^*.:^*v,*  THE     NEW 

THE  BEST  /imerican  standard 

Illustrated  Dictionary 

The  New  (9th)  Edition 


The  American  Illustrated  Medical  Dictionary.     A  new 

and  complete  dictionary  of  the  terms  used  in  Medicine,  Surgery, 
Dentistry,  Pharmacy,  Chemistry.  Veterinary  Science,  Nursing, 
and  all  kindred  branches;  with  over  loo  new  and  elaborate 
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^5.00  net;    with  thumb  index,  $5.50  net.       Published  September,  1917 
OVER  2000  NEW  WORDS  IN  THIS  EDITION 

For  tliis  edition  the  book  lias  betn  subjected  to  a  thorough  revision  and 
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than  a  medical  dictionary — it  is  a  Medical  Encyclopedia. 

Howard  A.  Kelly.  M.D.. 

Frojessor  of  Gynecologic  Surgery,  Johns  Hopkins  Universily,  Baltimore 

"  Dr.  Dorland's  Dictionary  is  admirable.  It  is  so  well  gotten  up  and  of  such  conve- 
nient size.     No  errors  have  been  found  in  my  use  of  it." 


Pilcher's  Practical  Cystoscopy 

Practical  Cystoscopy.  By  Paul  M.  Pilcher,  M.D.,  Con- 
sulting Surgeon  to  the  Eastern  Long  Island  Hospital.  Octavo  of 
504  pages,  with  299  illustrations,  29  in  colors.    Cloth,  $6.00  net. 

SECOND  EDITION— published  November,  1915 

To  be  properly  equipped,  you  mu.st  have  at  vour  instant  command  the 
information  this  book  gives  you.  It  explains  away  all  difficulty,  telling  you 
70//V  you  do  not  see  something  when  something  is  there  to  see,  and  telling  you 
/nmi  to  see  it.  All  theory  has  been  uncompromisingly  eliminated,  devoting 
every  line  to  practical,  needed  every-day  facts,  telling  you  how  and  when  to 
use   the  cystoscope  and  catheter — telling  you  in  a  way  to  make  you  A'uoxc. 

Bransford  Lewis,  M.  D.,  St.  Louis  Universily 

"  I  am  very  much  pleased  with  Dr.  Pilcher's  '  Practical  Cystoscopy.'  I  think  it  is  the 
best  in  the  English  language  now." 


DISEASES    OF   THE   EVE. 


Haab  and  DeSchweinitz's 
External  Diseases  qf  the  Eye 

(Published  February,  1909) 

Atlas  and  Epitome  of  External  Diseases  of  the  Eye. 

By  Dr  O.  Haab,  of  Zurich.  Edited,  with  additions,  by  G.  E. 
deSchweinitz,  M.  D.,  Professor  of  Ophthalmology,  University  of 
Pennsylvania,  loi  colored  illustrations  and  244  pages  of  text. 
Cloth,  ^3.00  net.  Third  Edition.  Saunders'  Atlases. 


Stokes'  The  Third  Great  Plague 

The  Third  Great  Plague:  A  Discussion  of  Syphilis  for 
Every=day  People.  By  John  H.  Stokes,  A.  B.,  M.  D.,  Head 
of  Section  on  Dermatology  and  Syphilology,  Division  of  Med- 
icine, The  Mayo  Clinic.     lamo  of  204  pages.      Cloth,  $1.50 

net.  Published  October,  1917 

American  Pocket  Dictionary      New  (loth)  Edition 

The  American  Pocket  Medical  Dictionary.  Edited  by  W.  A. 
Newman  Borland,  M.  D.  Containing  the  definition  of  the  principal 
words  used  in  medicine  and  kindred  sciences.  707  pages.  Flexible 
leather,  with  gold  edges,  $1.25  net;  with  thumb  inde.x,  $1.50  net. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior. 
I  can  recommend  it  to  our  students  without  reserve." — James  W.  Holland,  M.  D., 
Emerilus  Professor  of  Medical  Chemistry  and  Toxicology  at  the  Jefferson  Medical  College. 
Philadelphia.  Published  September,  1917 

J&cksOn  on  the  Eye  Prepanng—New  (3d)  Edition 

A  Manual  of  the  Diagnosis  and  Treatment  of  Diseases  of 
the  Eye.  By  Edward  Jackson,  A.  M.,  M.  D.,  Professor  of  Ophthal- 
mology, University  of  Colorado.  i2mo  of  615  pages,  with  184  illus- 
trations. 


saujvders'   books  on 


Barnhill  and    Wales' 
Modern     Otology 

A  Text=Book  of  Modern  Otology.  By  John  F.  Barn- 
hill,  M.  D.,  Professor  of  Otology,  Laryngology,  and  Rhinology, 
and  Earnest  de  W.  Wales,  M.  D.,  Clinical  Professor  of 
Otology,  Laryngology,  and  Rhinology,  Indiana  University  School 
of  Medicine,  Indianapolis.  Octavoof59S  pages,  with  314  original 
illustrations.     Cloth,  ^5.50  net. 

SECOND  EDITION 

This  work  represents  the  results  of  personal  experience  as  practitioners  and 
teachers,  influenced  by  the  instruction  given  by  such  authorities  as  Sheppard, 
Dundas  Grant,  Percy  Jakins,  Jansen,  and  Alt.  Much  space  is  devoted  to 
prophylaxis,  diagnosis,  and  treatment,  both  medical  and  surgical.  There  is  a 
special  chapter  on  ihe  bacteriology  of  ear  affections — a  feature  not  to  be  found 
in  any  other  work  on  otology.  Great  pains  have  been  taken  with  the  illus- 
trations.    A  large  number  represent  the  best  work  of  Mr.  H.  F.  Aitken. 

Frank   Allport,  M.  D., 

Professor  of  Otology,  North'MCstcrn  Utih'crsity,  Chicago. 

"I  regard  it  as  one  of  the  best  books  in  the  English  language  on  this  subject.  The 
pictures  are  especially  good,  particularly  as  they  are  practically  all  original  and  not  the  old 
reproduced  pictures  so  frequently  seen."  Published  January,  1911 


Davis'  Accessory  Sinuses 

Development  and  Anatomy  of  the  Nasal  Accessory 
Sinuses  in  Man.  By  Warren  B.  Davis,  M.  D.,  Corinna 
Borden  Keen  Research  Fellow  of  the  Jefferson  Medical  College, 
Philadelphia.  Octavo  of  172  pages,  with  57  original  illustra- 
tions. Published  March,  1914  Cloth,  $3.50  llCt. 
ORIGINAL  DISSECTIONS 

This  book  is  based  on  the  study  of  two  hundred  and  ninety  lateral  nasal 
walls,  presenting  the  anatomy  and  physiology  of  the  nasal  accessory  sinuses 
from  the  sixtieth  day  of  fetal  life  to  advanced  maturity.  It  was  necessary  for 
Dr.  Davis  to  develop  a  new  iechnic  by  which  the  accessory  sinus  areas  could 
be  removed  en  masse  at  the  time  of  postmortem  examinations,  and  still  per- 
mit of  reconstruction  of  the  face  without  marked  disfigurement. 


GENITOURINARY  AND  NOSE,  77/R()A7\  Eu.  g 

Greene  and   Brooks' 
Genito-Urinary  Diseases 

A  Text=Book  of  Genito-Urinary  Diseases.  By  Robert 
H.  Greene,  M.D.,  Professor  of  Genito-Urinary  Surgery  at 
Fordham  University;  and  Harlow  Brooks,  M.  D.,  Assistant  Pro- 
fessor of  ClinicalMedicine, Universityand  Bellevue Hospital  Medi- 
cal School.     Octavo  of  666  pages,  illustrated.     Cloth,  $5.50  net. 

FOURTH  EDITION— published  May.  1917 

This  new  work  covers  completely  the  subject  of  genito-urinary  diseases, 
]")resenting  dotk  the  medical  and  surgical  sides.  Kidney  diseases  are  very  elabo- 
rately detailed. 

New  York  Medical  Journal 

"  As  a  whole  the  book  is  one  of  the  most  satisfactory  and  useful  works  on  genito- 
urinary diseases  now  extant,  and  will  undoubtedly  be  popular  among  practitioners  and 
students." 


Gleason  on  Nose,  Throat, 
and  Ear 

A  Manual  of  Diseases  of  the  Nose,  Throat,  and  Ear.     By 

E.  Baldwin  Glkason,  M.  D.,  LL.  D.,  Professor  of  Otology, 
Medico-Chirurgical  College,  Graduate  School  of  Medicine,  Uni- 
versity of  Pennsylvania,  Philadelphia.  121110  of  590  pages,  pro- 
fusely illustrated.       Cloth,  ;^2.  75  net.  Published  October,  1914 

THIRD  EDITION 

Methods  of  treatment  have  been  simphfied  as  much  as  possible,  so  that  in 
most  instances  only  those  methods,  drugs,  and  operations  have  been  advised 
which  have  proved  essential.     A  feature  consists  of  the  collection  of  formulas. 

American  Journal  of  the  Medical  Sciences 

"  For  the  practitioner  who  wishes  a  reliable  guide  in  laryngology  and  otology  there  ar 
few  books  which  can  be  more  heartily  commended." 

Wilcox  on  Genito-Urinary  and  Venereal  Dis- 
eases Second  Edition,  published  Jeoiuary.  1909 

Essentials  of  Genito-Urtnary  and  Venereal  Diseases.  By 
Starling  S.  Wilcox,  M.  D.,  Lecturer  on  Genito-Urinary  Diseases  and 
Syphilologjr,  Starling-Ohio  Medical  College,  Columbus,  Ohio.  i2mo  of 
321  pages,  illustrated.  Cloth,  $1.25  net.  In  Saunders  Quesiwn-Com- 
pends. 


SAUA'DEJ^S'    BOOKS    ON 


Head's  Modern  Dentistry 

Modern  Dentistry.  By  Joseph  Head,  M.  D.,  D.D.S.,  Den- 
tist to  the  Jefferson  Hospital,  Philadelphia.  Octavo  of  374 
pages,  with  309  illustrations.     Cloth,  $5.00  net. 

Published  December,  1917 

Dr.  Head's  book  is  a  complete  and  up-to-date  text-book  on  dentistry. 
It  gives  you  the  principles  upon  which  successful  work  must  be  based — 
the  technic  in  full,  and  the  results  of  original  experiments,  with  formulee, 
instruments,  and  methods.  It  brings  out  clearly  the  \-arious  factors  which 
influence  the  diagnosis,  and  carefully  details  the  methods  of  treatment. 
The  subject  of  vaccines  is  gone  into  very  fully,  gi\ing  }ou  preparation  and 
use  of  autogenous,  stock,  and  special  vaccines.  Particularly  useful  are 
the  sections  on  mouth  hygiene,  local  anesthesia  by  novocain,  electrolysis, 
tooth  discoloration,  care  of  children's  teeth  and  gums,  orthodontia  for 
the  general  practitioner  of  dentistrj',  cement,  .v-ray  stud\',  and  the  use  of 
emetin.  Over  three  hundred  original  illustrations  show  the  student  just 
how  the  procedures  are  to  be  carried  out. 


Kyle's  Nose  and  Throat 

Diseases  of  the  Nose  and  Tliroat.  By  D.  Bradex  Kvle, 
M.D.,  formerly  Professor  of  Laryngology  in  the  Jefferson  Medical 
College,  Philadelphia;  Consulting  Laryngologist,  Rhinologist, 
and  Otologist,  St.  Agnes'  Hospital.  Octavo,  856  pages;  with 
272   illustrations   and   27  lithographic  plates    in   colors.      Cloth, 

tf  ,    -Q  net  Published  November,  1914 

FIFTH  EDITION 

This  work  has  now  readied  its  fiftli  edition.  With  the  practical  purpose 
of  the  book  in  mind,  extended  consideration  has  been  given  to  treatment,  each 
disease  being  considered  in  full,  and  definite  courses  being  laid  down  to 
meet  special  conditions  and  symptoms. 

Pennsylvania  Medical  Journal 

'■  l)r  Kyle's  crisp  terse  diction  has  enabled  the  inclusion  of  all  needful  nose  and  throat 
knowledge  in  this  book.  The  practical  man,  be  he  special  or  general,  will  not  search  in 
vain  for  anything  he  needs." 


CHEMISTRY  AXJ)    DEXTrSTR  Y 


Holland's 
Chemistry  and  Toxicology 

A  Text=Book  of    Medical   Chemistry   and    Toxicology, 

By  Tames  W.  Holland,  INI.  D.,  Emeritus  Professor  of  Medical 
Chemistry  and  Toxicology  ,  Jefferson  Medical  College,  Phila- 
delphia.    Octavo,  678  pages,  illustrated.     Cloth,  $3.00  net. 

FOURTH   EDITION— published  April.  1915 

Dr.  Holland's  work  is  an  entirely  new  one,  and  is  based  on  his  tliir'y-five 
vears'  practical  experience  in  teacliing  chemistry  and  medicine.  Recognizing 
that  to  understand  physiologic  chemistry  students  must  first  be  informed  upon 
points  not  referred  to  in  most  medical  text-books,  the  author  has  included  in  his 
work  the  latest  views  of  equilibrium  of  equations,  mass-action,  cryoscopv,  os- 
motic pressure,  etc.     Much  space  is  given  to  toxicology. 

American  Medicine 

"  Its  statements  are  clear  and  terse  ;  its  illustrations  well  chosen  ;  its  development  logi- 
cal, systematic,  and  comparatively  easy  to  follow.   .   .  .  We  heartily  commend  the  work." 


Ivy's  Applied  Anatomy  and  Oral  Surgery 

Applied  Anatomy  and  Oral  Surgery  for  Dental  Students. 
By  Robert  H.  Ivy,  M.  D.,  Li.  D.  S.,  Assistant  Oral  Surgeon  to  the 
Philadelphia  General  Hospital.  i2mo  of  290  pages,  illustrated.  Cloth, 
$1.75  net.  Second  Edition  published  July,  1917 

This  work  is  just  what  dental  students  have  long  wanted — a  concise,  practical  work 
on  applied  anatomy  and  oral  surgery,  written  with  their  needs  solely  in  mind.  No 
one  could  be  better  fitted  for  this  task  than  Dr.  Ivy,  who  is  a  graduate  in  both  den- 
tistry and  mediciner  The  text  is  well  illustrated  with  pictures  that  you  will  find  e.x- 
tremely  helpful. 

"I  am  delighted  with  this  compact  little  treatise.  It  seems  to  me  just  to  fill  the 
bill."— H.  P.  KuHN,  M.  D.,  lll-steru  Dental  College,  Kansas  City. 

Oertel  on  Bright's  Disease 

The  Anatomic  Histological  Processes  of  Bright's  Disease.  Bv 
HoRST  Oertel,  M.  D.,  Director  of  the  Russell  Sage  Institute  of  Path- 
ology, Xew  York.  Octavo  of  227  pages,  with  44  illustrations  and  6 
colored  plates.     Cloth,  ;S5.oo  net. 

These  lectures  deal  with  the  anatomic  histological  processes  of  Bright's  disease,  and 
■  in  a  somewhat  different  way  from  the  usual  manner.  Everywhere  relations  are  em- 
phasized and  an  endeavor  made  to  reconstruct  the  whole  as  a  unit  of  interwoven 
processes.  PubUshed  December,  1910 

"Dr.  Oertel  gives  a  clear  and  intelligent  idea  of  nephritis  as  a  continuous  process. 
"We  can  strongly  recommend  this  book  as  thoughtful,  scientific,  and  suggestive."— 
The  Lancet,  London. 


SAUXDEJ^S'    BOOA'S    ON 


Goepp's  Dental  State  Boards 


Dental    State   Board   Questions   and   Answers.     By  R. 

Max  Goepp,  M.  I).,  Professor  of  Clinical  Medicine  at  the  Phila- 
delphia Polyclinic.      Octavo  of  428  pages.     Cloth,  $3.00  net. 

SECOND  EDITION 

Tliis  new  work  is  along  the  same  practical  lines  as  Dr.  Goepp's  successful 
•work  on  Medical  State  Boards.  The  questions  included  have  been  gathered 
from  reliable  sources,  and  embrace  all  those  likely  to  be  asked  in  any  State 
Board  examination  in  any  State.  They  have  been  arranged  and  classified  in 
a  way  that  makes  for  a  rapid  resume  of  every  branch  of  dental  practice,  -and 
the  answers  are  couched  in  language  unusually  explicit — concise,  definite, 
accurate.  Published  February,  1916 


McConnell's  Pathology  and  Bacteriology  Dent&l 

General  Pathology  and  Bacteriology  for  Dental 
Students.  By  Guthrie  McConnell,  M.  D.,  .\ssistant 
Surgeon,   Medical  Reserve  Corps,   U.  S.  N.      121110  of  314 

pages,  illustrated.  Second  Edition  published  January,  1918 

This  work  was  written  expressly  for  dentists  and  dental  students,  em- 
phasizing throughout  the  application  of  pathology  and  bacteriology  in 
dental  study  and  practice.  There  are  chapters  on  disorders  of  metab- 
olism and  circulation  ;  retrogressive  processes,  cell  division,  inflam- 
mation and  regeneration,  granulomas,  progressive  processes,  tumors, 
special  mouth  pathology,  sterilization  and  disinfection,  bacteriologic 
methods,  specific  micro-organisms,  infection  and  immunity,  and  labora- 
tory technic. 


EVE,  EAR,  NOSE,  AND  TIIROAr.  13 

Bass  and  Johns*  Alveolodental  Pyorrhea 

Alveolodental  Pyorrhea.  By  Charles  C.  Bass,  M.D.,  Professor 
of  Experimental  Medicine,  and  Foster  M.  Johns,  M.  D.,  Instructor  in 
the  Laboratories  of  Clinical  Medicine,  Tulane  Medical  College.  Octavo 
of  168  pages,  illustrated.     Cloth,  $2.50  net.  Published  June,  1915 

This  work  discusses  alveolodental  pyorrhea  from  the  viewpoint  of  infection  liy  the 
iEndamoeba  buccalis  in  a  simple,  concise  way,  in  the  light  of  recent  ijiformalion. 

GleaSOn'S  Nose  and  Throat         Fourth  Edition,  Revised 

Essentials  of  Diseases  of  the  Nose  and  Throat.  By  E.  B. 
Gleason,  S.B.,  M.D.,  Clinical  Professor  of  Otology,  Medico-Chirurgical 
College,  Graduate  School  of  Medicine,  University  of  Pennsylvania, 
Post-octavo,  241  pages,  112  illustrations.  Cloth,  $1.25  net.  In 
Saunders'  Question-Compend  Series.  Published  October,  1914 

"The  careful  description  which  is  given  of  the  various  procedures  would  be  sufficient 
to  enable  most  people  of  average  intelligence  and  of  slight  anatomical  knowledge  to 
make  a  very  good  attempt  at  laryngoscopy." — The  Lancet,  London. 

Grant  on  the  Face,  Mouth,  and  Jaws 

A  Text-Book  of  the  Surgical  Principles  and  Surgical  Dis- 
eases OF  the  Face,  Mouth,  and  Jaws.  For  Dental  Students.  By 
H.  Horace  Grant,  A.  M.,  M.  D.,  Professor  of  Surgery  and  of  Clinical 
Surgery,  Hospital  College  of  Medicine,  Louisville.  Octavo  of  231  pages, 
with  68  illustrations.      Cloth,  ^2.50  net.  Published  September,  1911 

Preiswerk  and  Warren's  Dentistry 

Atlas  and  Epitome  of  Dentistry.  By  Prof.  G.  Preiswerk,  of 
Basil.  Edited,  with  additions,  by  George  W.  Warren,  D.  D.  S.,  Pro- 
fessor of  Operative  Dentistry,  Pennsylvania  College  of  Dental  Surgery, 
Philadelphia.  With  44  lithographic  plates,  152  text-cuts,  and  343  pages 
of  text.     Cloth,  ;^3.50  net.     Saufuieii  Hand- Atlases.  August,  1906 

Grunwald  and  Grayson  on  the  Larynx 

Atlas  and  Epitome  of  Diseases  of  the  Larynx.  By  Dr.  L. 
GrOnwald,  of  Munich.  Edited,  with  additions,  by  Charles  P. 
Grayson,  M.  D.,  University  of  Pennsylvania.  With  107  colored  figures 
on  44  plates,  25  text-cuts,  and  103  pages  of  text.  Cloth,  ^^2.50  net.  In 
Satinde7-s'  Hand-Atlas  Series.  Published  1898 


Mracek  and  Stelwagon's  Atlas  of  Skin 


Second 
Edition 

Atlas  and  Epitome  of  Diseases  of  the  Skin.  By  Prof.  Dr. 
Franz  Mracek,  of  Vienna.  Edited,  with  additions,  by  Henry  W\ 
Stelw^agon,  M.  D.,  Jefferson  Medical  College.  With  77  colored 
plates,  50  half-tone  illustrations,  and  280  pages  of  text.  Cloth,  $4.00 
net.     /;/  Sautiders'  Hand-Atlas  Series.  Published  July,  1905 


t4  SAL'XJJEKS'   /WOKS  ON 

Theobald's 
Prevalent  Diseases  of  the  Eye 


Prevalent  Diseases  of  the  Eye.  By  Samuel  Theobald, 
M.  D.,  Clinical  Professor  of  Ophthalmology  and  Otology,  Johns 
Hopkins  University.  Octavo  of  550  pages,  with  219  text-illustra- 
tions and    10  plates.       Cloth,  $4.50  net.  Published  July,  1906 

Chas.  A.  Oliver,  M.  D., 

Clinical  Professor  of  Of>hthaUnology,  Wotnan's  Medical  College^  Phila. 
"  I  feel   I  can  conscientiously  recommend   it,  not  only  to  the  general  physician  and 
medical  student,  but  also  to  the  experienced  ophthalmologist." 


Wells'  Chemical  Pathology 

Chemical    Pathology.      By  H.   Gideon   Wells,    Ph.D., 

M.  D.,    Professor    of  Pathology  in  the  University  of  Chicago, 

Octavo  of  616  pages.      Cloth,  $3.25  net.  Second  Edition 

Published  March,  1914 
Wm.  H.Welch,  lA.D., Johns  Hopkins  University. 

"  The  work  fills  a  real  need  in  the  English  literature  of  a  very  important  subject,  and  I 
shall  be  glad  to  recommend  it  to  my  students." 


Stel wagon's  Essentials  of  Skin        seventh  Edition 

Essentials  of  Diseases  of  the  Skix.  By  Hexrv  W.  Stelw.-vgox, 
M.  D.,  Ph.  D.,  Professor  of  Dermatology  in  the  Jefferson  Medical 
College,  Philadelphia.  Post-octavo  of  292  pages,  with  72  text-illustra- 
tions and  8  plates.  Cloth,  $1.25  net.  In  Saunders'  Question-Corn pcnd 
Series.  Published  August,  1909 

"In  line  with  our  present  knowledge  of  diseases  of  the  skin.  .  .  .  Continues  to  main- 
tain the  high  standard  of  excellence  for  which  these  question  compends  have  been 
noted." — The  Medical  News. 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsi.stx) 

RD  156  IV187  C.1 

American  addresses    


2002106841 


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